The Ontario Mental Health Summit by jackhirose

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Live In-Person & Live Stream Conference

November 27–29, 2023 Monday-Wednesday 8:30am to 4:00pm

Oakville, ON

Oakville Conference Centre 2515 Wyecroft Road

FEATURED SPEAKERS

The ONTARIO

Mental HEALTH SUMMIT

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

Eboni Webb

Jeff Riggenbach

Daphne Fatter

Ph.D.

Psy.D.

Ph.D.

Choose From 26 Workshop SEssions TOPICS FOR: Counselling-Focused, School-Focused & All Professionals •• Addressing the Emotional Roots of Anxiety & Agitation

Lynne Kenney Psy.D.

Carissa Muth Psy.D.

SPONSors

•• Trauma & Attachment •• Disarming High Conflict Students in the Classroom •• Traumatic Memory & Best Practices for EMDR •• Why Our Children’s Mental Health is Deteriorating & What Can Be Done About It •• Working with the Highly Dysregulated Child •• Using IFS-Informed EMDR for Complex Trauma •• Healing the Healer •• Internal Family Systems Therapy for Trauma Treatment

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

•• CBT Strategies that Really Work with Students in the Classroom

•• Strengthen Executive Function, Attention, Memory, Response Inhibition & Self-Regulation in Children & Adolescents •• Navigating Addictions •• Polyvagal Theory and Trauma-Informed Stabilization Tools •• Trauma-Focused DBT •• The Personality Disorder Toolbox •• Neufeld’s Traffic Circle of Frustration: A Revolutionary Approach to Aggression, Depression & Suicide •• 20 Empirically-Based Art, Music, Movement & Thinking Skills Activities to Improve Behaviour & Learning in Children & Adolescents •• Mastering the Core Skills & Competencies of CBT •• Resilience & the Stress Response

JACKHIROSE.COM | 1.800.456.5424

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

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

WE ARE PLEASED TO WELCOME YOU TO A JACK HIROSE & ASSOCIATES CONFERENCE. If you have any questions or concerns throughout the day, please notify your on-site coordinator. PLEASE REMEMBER: • Wear your name badge every day • Turn off your cell phone • Hand in your evaluation forms at the end of each day • If you have pre-purchased lunch your tickets are in your name badge, please treat your tickets like cash. •

If you have not pre-purchased lunch there is a limited amount available on a first come, first serve basis.

SCHEDULE: This schedule may vary depending on the flow of the presentation and participant questions 7:30am – 8:30am 8:30am – 10:30am 10:30am – 10:45am 10:45am – 11:45pm 11:45pm – 12:45pm 12:45pm – 2:15pm 2:15pm – 2:30pm 2:30pm – 4:00pm 4:00pm

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

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Addressing the emo.onal roots of

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

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

Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

ANXIETY

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

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

• mediated through special NEUROTRANSMITTERS in the nervous system

alarm system

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

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

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

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

facing separation

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

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

of .. lacknging losing face with . can’t be wNEGLECTED ith ... belo ct ... y c,on ne reje

c n’t ca

fe eli not ma ng Rerin dif g to . fe .. re nt

isola tion

not important to ...

feel

ing

unlo ved by

facing ing separation g n belo n ot

...

t no

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r de un

d by ... not recognize

ced repla

by ...

ed th nt disc reats to identity being alone a . ou n o .. tw ecial t ted no n o t sp by . n .. old o BETRAY ED can’t hn apart Y ... B O e wh ON T HELD NOT LIKED BY ... NOT

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

• when felt, has a signiﬁcant TEMPERING eﬀect on behaviour

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

alarm as an emotion

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

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

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

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

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

alarm system

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

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

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

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

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

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

facing separation

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

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

Adapting to Alarming Separation that Cannot be Avoided

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

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

inner conﬂict must be FELT for alarm to be tempered

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

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

DESIRE

ALARM

to engage in an activity

to be away from home

to take part in some fun

to be laughed at

to ask one’s question

ALARM & DESIRE

to appear stupid

to stand up for a friend

to lose popularity

to wear what one prefers

to be seen as different

to share one’s story

to not be interesting

to express one’s opinion

to meet disapproval

to get attached & involved

to have to let go

to pursue a passion

to not measure up

to be oneself

to be alone

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

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

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

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

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

TRAITS DERIVED FROM A WELL-FUNCTIONING ALARM SYSTEM

• REFLECTIVE

• CAREFUL

• characterized by a conﬂicted RELATIONSHIP with alarm

• CAUTIOUS • CONCERNED • CONSCIENTIOUS

• RESOLUTE – not controlled by alarm

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

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

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

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

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

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

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

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

felt vaguely as unsafe, uneasy or apprehensive

••• • •

alarm is dysfunc:onal

alarm is perverted

AGITATION, ATTENTION, & DISCIPLINE problems

ADRENALIN SEEKING problems

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

• • HIGHLY ALARMED

•• •• •

The Continuum of ALARM Problems alarm is displaced

alarm is dysfunc:onal

it t s nalarm is iperverted

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

A Continuum of Defendedeness ANXIETY - based

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

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

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

SYMPTOMS

OF PRIMAL EMOTION

COGNITION-

BASED DERIVATIVES OF PRIMAL EMOTION

PRIMAL EMOTION

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

OBSESSIONS

mistaken assump,ons regarding what’s wrong

ALARM triggered by facing separation

TRIGGERING EXPERIENCE

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

IRRATIONAL OBSESSIONS

RESULTING COMPULSIONS

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

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

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

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

• something is out of order or out of place

work at putting things in order and their place

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

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

• some places or situations are dangerous or unsafe

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

• something has been left undone

work at remembering to complete one’s tasks

• one is ‘too much’ or ‘not enough’

work at editing or enhancing, diminishing or improving oneself

(mistakes regarding ‘what’s wrong’)

(to avoid or reduce alarm)

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

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

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

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

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

UNTEMPERED – inner conﬂict is NOT felt

CARELESS and RECKLESS – NOT moved to cauFon ALARM

NOT FELT DIRECTLY

... ATTENDING TO WHAT TRULY ALARMS

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

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

immaturity -based

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

COMMON ATTENTION PROBLEMS

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

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

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

Anxiety & Agita,on - Gordon Neufeld

a%racted to, & engaged by, WHAT ALARMS

Jack Hirose Seminars - Fall, 2023

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

... ALL VULNERABLE FEELINGS

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

• unreﬂec,ve

• can become a troublemaker

• unconﬂicted • inconsiderate

• can lack a conscience

• unfeeling

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

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

n e rv o u

s does alarming things

S SION BSES

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

AGIT

reckless & careless

worry

O panic comp ulsio ns

CTED TMOS ATTRA LAR WHAT A

overconscien.ous N ATIO .cs

sity g curio lackin

facing separation

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

FEAR

LESS

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

• not safe to depend

HA LP

CIN GM OR

• peer orienta,on

M NG MI

• failure to develop the capacity for rela,onship

• failure of adults to inspire dependence

CO BE

• premature separa,on

and less able to deal with it

• peer orienta,on

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

RA T ES EP A

embed in cascading care

HA LP

CIN GM

M NG MI

CO BE

reduce the separation they are facing

IO N

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

LOSING THEIR FEELINGS Safe caring relaFonships

make it safe to feel

EmoFonal Playgrounds

EVIDENCE-BASED, POWERFUL and SAFE UNIVERSAL in APPLICATION

INDIRECT and NON-INTRUSIVE

RELATIONAL & PLAY-BASED interven.ons

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

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

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

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

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

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

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

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

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

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

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

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

of trusting dependence

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

• lead into MIXED FEELINGS if inner conﬂict exists

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

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

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

• SADNESS is much easier accessed in the play mode

• play provides temporary REST and RELIEF from alarm

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

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

• obsessions and compulsions can be DEFUSED in play

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

• ATTENTION problems are best addressed through play

Play Holds the Most Promise

attachment -based

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

ATTENTION PROBLEMS ALARM -based

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

hypersensitivity based

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

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

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

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

TIO RA ES EP A OR

HA LP

CIN GM

embed in cascading care

R MO NG MI

reduce the separation they are facing

CO BE

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

LOSING THEIR FEELINGS make it safe for children to feel

11/26/2023

Trauma & Attachment Across the Lifespan Tools & Strategies to Address Complex Clients 1

The Neurobiology of Trauma

“

Often and often afterwards, the beloved Aunt would ask me why I had never told anyone how I was being treated. Children tell little more than animals, for what comes to them they accept as eternally established. Rudyard Kipling 3

11/26/2023

Essential Developmental Target: Dysregulation to Co-Regulation

Excessive Cortisol Effects • Neurotoxicity to Hypothalamus • Neuron Death • Clogging of the corpus callosum connecting the left and right hemispheres • Suppression of the immune system 5

Features • Reactionary • Triggers Sensory System (Smell and Touch are the most direct pathways) • Controls autonomic responses

http://www.dynamicbrain.ca/brain-anatomy-images.html

11/26/2023

What Happens During A Stress/Trauma Response?

HYPERAROUSAL

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

HYPOAROUSAL

Stress Management Our Body’s Natural Defense

11/26/2023

Hormonal Counter to Cortisol=Oxytocin

Dysregulation as a Learned Response Cortisol is Released

Distress Forms Dysregulation Pattern

Invalidating Environment

Cortisol=automatic reaction.

How Problematic Auto-Regulation is Learned

Oxytocin

Cortisol

SelfSoothe

Stress

Behavior

11/26/2023

Treatment Targets to Increase Oxytocin Without Problem Behaviors Activities

Hugs Sing in a choir ╺ Give a back rub/foot rub ╺ Hold a baby ╺ Stroke a dog or cat ╺ Perform a generous act ╺ Pray

Make positive eye contact Breath work ╺ Listen without judgment ╺ Positive touch ╺ Proximity ╺ Laugh/Dance

╺

What is your

Attachment style?

Democratic-Authoritative Parenting High nurturance, expectations, and control Moderate communication

Abusing-Authoritarian Parenting High expectations and control Low nurturance and communication

11/26/2023

Neglecting-Uninvolved Parenting

Indulgent-Permissive Parenting

Low nurturance, expectations, control and communication

High nurturance, moderate communication, low expectations, and control

Common Types of Invalidation Abuse and neglect Open rejection of thoughts, feelings, and behaviors ╺ Making “normal” responses “abnormal” ╺ Failing to communicate how experience “makes sense” ╺ Expecting behaviors that one cannot perform (e.g., due to developmental level, emotionality, or behavioral deficits ╺ ╺

Five Movements Mindfulness

11/26/2023

Character Strategies and Trauma in Development 19

What are Character Strategies?

Sensitive to Dependent Endearing

Sensitive Emotional

Essential Self

Sensitive Withdrawn

Trauma Timeline In utero to 2 years of age

SelfReliant

Oral Strategies (Farca 2018, Ogden 2007)

11/26/2023

THE SENSITIVE-EMOTIONAL (Farca 2018, Ogden 2007) • “Help or I’ll die.” • “My existence isn’t secure.”

• Panic • Fear

• DisorganizedUnresolved with ambivalentpreoccupied tendencies

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• Self-Soothe • Ventral Vagal Development

THE SENSITIVE-WITHDRAWN (Farca 2018, Ogden 2007) • Panic • Fear

• Disorganizedunresolved with avoidantdismissing tendencies

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• “I’ll die if I move” • “Life is dangerous”

• Co-Regulation • Ventral Vagal Development

THE DEPENDENTENDEARING (Farca 2018, Ogden 2007) • Despair • Hopelessness • Shame • Sadness

• Ambivalentpreoccupied tendencies

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• “If you aren’t there for me, I’ll be hurt.” • “I’m going to die.”

• Body Alignment • Core Strengthening

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THE SELF-RELIANT (Farca 2018, Ogden 2007) • Fear • Terror

• AvoidantDismissing

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• “If I stay, I’ll die.” • “I can do it on my own. I don’t need to connect”

• Dependency • Connection

Psychopathic to

Trauma Timeline 3 to 5 years of age

Tough Generous

Burdened Enduring

Industrious Overfocused

Essential Self

Charming Manipulative

Industrious Strategies Expressive Clinging

(Farca 2018, Ogden 2007)

THE TOUGH GENEROUS (Farca 2018, Ogden 2007) • Anger • Rage

• AvoidantDismissing

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• “Kill or I’ll die.” • “Don’t be a baby.” • “I can’t be vulnerable.”

• Exploration • Validating Safe Base

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THE CHARMING MANIPULATIVE (Farca 2018, Ogden 2007) • Fear • Terror

• Ambivalentpreoccupied tendencies

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• “If I stay, I'll die” • “I can’t be direct or genuine.”

• Autonomy

THE BURDENED ENDURING (Farca 2018, Ogden 2007) • Panic • Hopelessness • Despair • Sadness

• Avoidant or ambivalent tendencies

Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• “I’ll die if I move” • “I can take it on and if I can, I’ll be loved.”

• Autonomy

THE INDUSTRIOUS OVERFOCUSED (Farca 2018, Ogden 2007) • Rage • Terror • Anger • Fear

• Avoidantdismissing tendencies

Emotions

Traumatized Belief

• “Stay or die” • “If I try better, harder, and am more motivated, I’ll get it and I’ll be loved.”

Parental Attachment Style

Attachment Deficits

• Affirmation

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THE EXPRESSIVE CLINGING/ATTENTION-SEEKING (Farca 2018, Ogden 2007) • Rage • Panic • Anger • Fear

• Ambivalentpreoccupied tendencies

• ““Pay attention to me!” • “Help or I’ll die” Emotions

Traumatized Belief

Parental Attachment Style

Attachment Deficits

• Attention • Validation

TRAUMA RECOVERY VISION #1

REGULATIO N WHAT ARE THE TYPES OF DYSREGULATION? 32

Types of Dysregulation

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TRAUMA RECOVERY VISION #2 MENTAL CLARITY VICTIM MIND

SURVIVOR MIND

RECLAIMED MIND

FROM A TRAUMA STATE TO A CLEAR STATE OF MIND……. Sex

Alcohol

SelfHarm IT DIDN’T REALLY HAPPEN

G U I L T

P A I N

IT REALLY HAPPENED

NEW SELF

HOPE

IT REALLY HAPPENED TO ME

Work Drugs 35

Eating Disorders

VOICE

HEAL

TRAUMA RECOVERY VISION #3

RELATIONAL SURRENDER WHAT DOES IT LOOK LIKE TO SURRENDER AFTER TRAUMA? 36

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BODY CENTERED AND GROUNDED

EMOTIONALLY REGULATED

RESET SURVIVAL DEFENSES

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RAGE

GROUP CHAOS

TERROR

POSSESIVE JEALOUSY

PANIC

HYPERAROUSAL

FEAR SADNESS SHAME

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

ANGER

HYPOAROUSAL

JEALOUSY

FEIGNED COMPLIANCE

DISSOCIATION PSYCHOTIC BEHAVIOR

ORGANIZED STORYTELLING

Core Organizers of Our Experiences ╺

╺

Thoughts Emotions Sensations Urges Movements

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What Does Earned Security Look Like? 43

Survivors Group

SECURE BASE

Sponsor

Safe Housing

Therapist Coaches PROXIMITY MAINTENANCE

SAFE HARBOR

HEALING

Physician

Case Management

Body

HOLISTIC THERAPY

Therapy

Family

Mind

LET’S TAKE A BREAK!

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Key Childhood to Adult Disorders 46

Anxiety •

•

Anxiety is an adaptive response to threat (and the traumatized client expects threat) Validate the feelings and sensations as real and experientially work with the somatic experience that the feelings are intolerable Balance mindful acceptance of anxiety with relaxation and grounding skills(e.g., breathing, muscle relaxation, positive self-talk, self-soothing skills) Realign therapeutic environment that threatens to dysregulate your client.

Attention-Deficit/Hyperactivity Disorder •

•

Assess for history of Traumatic Brain Injury as recent studies indicate a correlation between trauma and ADHD (McIntosh, 2015) Hypervigilance resembles hyperactivity and might be easily misinterpreted (Littman, 2009) Focus on nutritional management strategies-hydration, omega-3 fatty acids, targeted amino acid therapy (TAAT) (Purvis et al, 2007) Assess for compromised parenting as impulsivity and compromised executive functioning inhibits proximity maintenance and structuring the environment appropriately (e.g. safe harbor) Target in-session activities that activate the observing mind and a restful mind state

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Acute Response to Threat Study Hyperaroused Continuum

Rest (Male Child)

Vigilance (crying)

Resistance (Freeze)

Defiance (posturing)

Aggression (hitting, spitting,etc)

Dissociative Continuum

Rest (Female Child)

Avoidance (Crying)

Compliance (Freeze)

Dissociation (Numbing)

Fainting (checking out, mini-psychosis)

Primary Brain Areas

Neocortex

Subcortex

Limbic

Midbrain

Brainstem

Cognition

Abstract

Concrete

Emotional

Reactive

Reflexive

Acute Response to Threat; (Perry, Pollard, Blakely, Baker & Vigilante, 1995). Adapted from study results for teaching.

Mental State

Calm

Arousal

Alarm

Fear

Terror

Oppositional Defiant Conduct Disorder • •

•

Multifamily attachment interviews Bring a family therapist on the team and open up multifamily trauma skills training to all supporting family members If there is an extensive history of trauma, practice strategies of avoiding the word “no” as it sends the child out of his or her window. Keep child’s world small and predictable with immediate consequences

Attachment Disorders Stability first! Child must have skills to tolerate distress and remain in the window (e.g., work on grounding skills, distress tolerance, and emotion regulation) ╺ Incorporate emotion regulation strategies that hyper or hypoarousal patterns(e.g. aggressive connection or dissociated drifting to strangers) ╺ Develop healthy connective strategies through somatic exercises ╺ Teach boundaries and learning how to sense the body for child and parent ╺

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Trauma Timeline (Keck)

PTSD and Trauma Utilize ”parts” work in sessions to identify dissociated emotions, thoughts and memories (Fisher, 2017) ╺ Embody and model mindfulness skills ╺ Utilize somatic interventions should client leave the window ╺ Incorporate Connected Child (Purvis, et.al, 2007) work into work regarding discipline strategies (e.g. Trust Based Relational Interventions (TBRI) ╺

Structural Dissociation Trauma

Daily Coping

Worker

Caretaker

Emotional Coping

Survival Defenses

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PARTS WORK ACTIVITY: INDUSTRIOUS OVERFOCUSED PART

Eating Disorders and Alexithymia  2/3 report a lack of ability to identify emotions and will often somaticize experiences (Van der Kolk, 2015)

 Key Character Strategies: Oral (Dependent Endearing / SelfReliant)

 Practice various levels of relational, emotional, psychological nourishment

THE DEPENDENTENDEARING (Farca 2018, Ogden 2007) • Despair • Hopelessness • Shame • Sadness

• Develop awareness of needs • Delay gratification • Provide relational support

Emotions

Traumatized Belief

Treatment Goals

Attachment Deficits

• “If you aren’t there for me, I’ll be hurt.” • “I’m going to die.”

• Body Alignment • Core Strengthening

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THE SELF-RELIANT (Farca 2018, Ogden 2007) • Fear • Terror

• Reconnecting • Building relationships • Learn to receive support

Emotions

Traumatized Belief

Treatment Goals

Attachment Deficits

• “If I stay, I’ll die.” • “I can do it on my own. I don’t need to connect”

• Dependency • Connection

Depression  Depression in trauma happens when survival strategies are frustrated, making hope difficult and leading to greater passivity.  Validate the mood, especially given lack of positive experiences (reduces secondary guilt and shame).  Focus on activating responses in the body.  Build mindfulness practice.  Build in self-care and emotion naming and resourcing skills  Key Strategy: Burdened Enduring

SUBSTANCE ABUSE AND DEPENDENCE Validate needs and challenge means of meeting those needs Increase mindfulness of urges and then shift to external focus ╺ Decrease environmental triggers ╺ Increase distress tolerance and emotion regulation to deal with withdrawal and urges ╺ ╺

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Addiction and Trauma

Approximately 2/3 of all addicts report experiencing some form of physical or sexual trauma during childhood. (Dualdiagnosis.org)

DBT-SUD ADDICTION MIND

CLEAN MIND

CLEAR MIND

Emotion Dysregulation: The “Core” Deficit of Personality Disorders Many causes of emotional sensitivity (e.g., attachment problems, loss, trauma, invalidation)  Connected to neurochemistry although mediated by psychological factors  High emotional arousal predicts increased susceptibility in the future due to kindling effects  Emotion dysregulation leads to escape and avoidance behaviors in BPD and other personality disorders 

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Personality Disorders & Trauma Sensitive Emotional Containment Boundaries

Borderline Dependent

Maintain Proximity Regulate Intensity

Sensitive Withdrawn Schizoid Paranoid

Sensory Processing Spectrum Disorders

Connection Body Awareness

Directed Proximity Autonomy

Self-Reliant Obsessive-Compulsive Paranoid

Avoidant

Collaboration Validation

Softening Boundaries Regulate Intensity

Personality Disorders & Trauma Dependent Endearing Empowerment Self-Validation

Borderline Dependent

Needs Assertion Delaying of Gratification

Tough Generous Antisocial Borderline

Obsessive-Compulsive

Surrender Authenticity

Boundaries Grounding

Charming Manipulative Narcissistic Histrionic

Borderline Dependent

Mindfulness Self-Validation

Authenticity Making Direct Requests

Personality Disorders & Trauma Burdened Enduring Borderline Obsessive Compulsive

Avoidant

Activation Self-Validation

Needs Assessment Assertive Communication

Expressive Attention Seeking Antisocial Borderline

Narcissistic Schizotypal Histrionic Obsessive Compulsive

Narcissistic Histrionic

Borderline Antisocial

Mindfulness Containment

Explore the source of attention-seeking

Industrious Overfocused Obsessive Compulsive

Rest Self-Compassion

Collaboration Self-Validation

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Critical Interventions: Building the Therapist’s Resource Toolkit

Boundaries Authoritative Therapy: Proximity Maintenance 68

Containment

Screening

Protection

Envision the Human Cell

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Proximity Exercise 70

Prosodic Communication

• Pitch • Intonation • Rhythm • Loudness • Tempo • Stress

The Therapeutic Space Seating Windows Lighting Smells Fidgets Food Weighted blankets Spacing

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Validation The Keys to the Kingdom 73

Levels of Validation (Linehan, 1997) • • • • • •

Level 1: Being acutely attentive Level 2: Reflecting verbal communication Level 3: Describing non-verbal communication Level 4: Expressing how experience makes sense given history or biology Level 5: Expressing how experience makes sense in the present moment and context Level 6: Being in genuine, human contact

EMOTIONAL VULNERABILITIES

ACTIVE PASSIVITY

UNRELENTING CRISIS BIOLOGICAL SOCIAL

APPARENT COMPETENCE

INHIBITED EXPERIENCING

SELFINVALIDATION 75

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SelfInvalidation

• Self-hate/criticism • People-pleasing • Perfectionism

Emotional Vulnerability

• Anger, Bitterness Towards Others • Fragility, Vulnerability

Inhibited Experiencing

• Active avoidance • Passive avoidance, dissociation

SelfInvalidation

• Modeling failure • Communicating validation

Emotional Vulnerability

• Model self-care • Create a safe therapeutic environment

• Model Emotions Inhibited • Display authentic reactions Experiencing without exaggeration 77

Unrelenting Crises Active Passivity Apparent Competence

• Uncontrollable Events • Crisis-Generating Behavior

• Willfulness, Demandingness • Helplessness

• Disconnect between verbal and non-verbal behavior • Contextual Competence (mood/situational)

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Unrelenting Crises Active Passivity Apparent Competence

• Control the Controllable in treatment • Practice/Model Delayed Gratification

• Cheerlead • Encourage problem-solving • Set Personal Limits

• Highlight effective behaviors observed • Lose the assumption of how the client “should” behave in all contexts based upon one.

Reciprocal Communication Engaging and responsive, taking clients wants and needs seriously ▫ Being authentic and genuine, not staying in a “therapist” role ▫ Using self-disclosure thoughtfully in the service of therapy ▫

Reciprocal Communication: Self-involving disclosure Sharing “benign” and human examples of skill use and practice Using examples of how you have approached and solved a problem ▫ Sharing when you would have felt, thought, or responded similarly to how a client reports in a given situation ▫ Sharing your reactions to the client in the moment, providing information that manages relationship contingencies (creating new learning) ▫ Letting the client know about the current state of the relationship, to manage contingencies or address feared reactions ▫ ▫

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Self-disclosure of Personal Information Personal information may not relate to client or the therapy; if it is not relevant, do not share it as a rule ▫ Observe and disclose your limits in regard to personal information when needed (ok to explore what personal inquiries mean to the client) ▫ Never share personal problems/issues! ▫ Does it pass the “public” test? In other words, would you share it in front of an audience of your colleagues? ▫

In Summary

Trauma: Is broad, self-perceived, and activates survival defenses to cope. It can come in multiple forms including single-incidents and developmental. Stress Response: Dysregulation is a learned response that is neurobiologically driven and socially maintained. Attachment: Human survival and attachment is dependent on communication, eye-gazing, and finding a way to “fit.” It is essential when working with trauma to see behaviors as “attachment-seeking behaviors” Whole Body Healing: We must seek healing of the body in order to heal the mind. Our functioning isn’t either or but both and. Complex Treatment Strategies: Treatment must be multifaceted including top-down and bottom-up processing techniques. DBT, EMDR, SP, and somatic therapies must be utilized to address the lasting impact of trauma.

The impulse to heal is real and powerful and lies within the client. Our job is to evoke that healing power, to meet its tests and needs and to support it in its expression and development. We are not the healers. We are the context in which healing is inspired. Ron Kurtz

11/26/2023

Thank-You • Eboni Webb PsyD, HSP ewebb@webbjamconsulting.com 615-589-1018 The Village of Kairos 1451 Elm Hill Pike, Suite 250 Nashville, TN 37210 367 Riverside Drive, Suite 104 Franklin, TN 37064

1. Direc(ons for Prac(ce Time Get into Pairs and take 15 minutes each to ask your partner these ques7ons. It’s a Choice if you want to add slow Bu@erfly Hug to enhance access to these resources in the body. 1. “Have you ever felt significant affirma7on and belonging because of your iden7ty/race/culture? Are there groups, gatherings, or celebra7ons (including places of worship, tradi7ons or fes7vals) that create a sense of social support for you?” (Social Capital) 2. “What skills, strengths, or intui7on have allowed you to navigate any language differences, nego7ate living in two works and/or maneuver through systems that are unfriendly, dangerous, and full of hurdles for those not in the dominant culture?” (Cultural Intui7on, Naviga7onal & Linguis7c Capital)

3. “During your hardest 7mes naviga7ng challenges associated with your iden7ty/race/culture, how did you keep going? Are there any spiritual/religious beliefs and prac7ces and/or people that helped you endure and make meaning of diﬃcul7es” (Aspira7onal & Spiritual Capital)

EMDR Phase 1: Client History

Identity, Race, & Culture Interview I would like to ask you some questions about your identity, race, and culture and first want to recognize that we have differences and similarities. Do you have any questions or concerns about my identity/race/culture? Do you have questions or concerns about how our differences or similarities may impact your comfort, safety, and the effectiveness of your treatment? I’m curious if you feel comfortable with me asking you some questions about your experiences with your identity, race, and culture? If yes: How would you identify yourself in each of these areas (both past and present if they have evolved)? Are there ways others would identify you that you don’t feel fits you? PLEASE ONLY PROVIDE ANSWERS TO THOSE ASPECTS YOU FEEL COMFORTABLE DISCLOSING AT THIS POINT. Age / Generation Ethnicity / Race / Ancestral background Family role / Marital status Sex / Gender Identity Sexual Orientation / Sexual preferences Religion / Faith Hobbies / Social interests Political views Education level / School affiliation Intellectual style or ability/disability Occupation / Career Economic status/ Social class Neighborhood / Region Immigration status / Citizenship Physical ability/disability Physical appearance Health status / Medical diagnosis Mental health status/diagnosis Which of these aspects of your identity/race/culture do you consider to be most important to who you are? Which 3 (approx) have the most significant positive associations? [Circle them above] Which 3 (approx) have the most significant negative associations? [Square them above]

Adapted from Alter-Reid, K., Angelini, C., Chang, S., Gattinara, P., Grey, E.,Hearting, J., Heber, R., Juhasz, J., Levis, R., Levis, R., Lutz, B., Marich, J., Masters, R., McConnell, E., Monteiro, A., Nickerson, M., O’Brien, J., Onofri, A., Robinson ,N., Royale, L., Seubert, A., Shapiro, R., Siniego, L., & Yaskin, J. In Nickerson, M.I. (Ed.), Cultural Competence and Healing Culturally-Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. New York, NY: Springer. Edited in consultation with Chaffers, Q., Hamilton, H., Kase, R., Marich, J., & Urdaneto Melo, V. and the EMDRIA Diversity, Community & Culture SIG (personal communication, July 2020). Promoted by Diane Desplantes, LCSW and developed by Colette Lord, PhD & Susanne Morgan, LMFT ~ EMDR Readiness Academy (Updated 9/2021) Open Permission Granted to Share and Reprint

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The following questions may be asked directly, but the information may also be more appropriately gathered during the course of more natural narrative history gathering. The questions should be posed thoughtfully, with consideration to timing (sufficient therapeutic alliance) and method (as indirect phrasing as suggested by Levis & Siniego (2016) may create a safer context for the client). Not all of the questions below need to be asked, but only those that seem to be clinically fitting for each client. Questions specifically eliciting Community Cultural Wealth Resources (CCRW – Levis, 2016) are noted in italics.

Have you ever felt significant affirmation and belonging because of your identity/race/culture? Are there groups, gatherings, or celebrations (including places of worship, traditions, or festivals) that create a sense of social support for you? (Social Capital)

From whom did you learn lessons about friendship, love, travel, adventure, family values, education, faith, religion? Do you have any role models or mentors who share your identity/race/culture? What skills or strengths do you admire in them that you have (or would like to) develop in yourself? Who would be proud of you for how you are handling challenging experiences associated with your identity/race/culture? (Familial & Social Capital)

What skills, strengths, or intuition have allowed you to navigate language differences, negotiate living in two worlds, and/or maneuver through systems that are unfriendly, dangerous, and full of hurdles for those not in the dominant culture? (Cultural Intuition, Navigational & Linguistic Capital)

Did you ever feel different because of any aspect of your identity/race/culture? When did you start noticing that? What were the messages you received around that difference?

Have you ever been misjudged, misunderstood, held back, harmed, or physically assaulted because of any aspect of your identity/race/culture? If so, was action taken to validate, rectify, or repair what happened? With whom did you feel safe to share what happened? What knowledge, skills, empowerment, or pride have you developed in resisting subordination and oppression? (Resistant Capital)

Have any of your immediate or extended family experienced misjudgment or discrimination because of their identity/race/culture? If so, was action taken to validate, rectify, or repair what happened? How was this spoken of within the family?

Was there a transition to accepting any aspects of your identity/race/culture? Have you ever felt the need to hide any aspect of your identity/race/culture? Are there sacrifices you have made (or anticipate may be necessary) associated with navigating differences between your identity/race/culture and the dominant culture?

During your hardest times navigating challenges associated with your identity/race/culture, how did you keep going? Is your determination related to others whose dreams or well-being depend on you practically or as a role model? Are there spiritual/religious beliefs and practices that help you endure and make meaning of difficulties in relation to your identity/race/culture? (Aspirational & Spiritual Capital)

What has it been like for you to be talking to me, a(n) _____ (therapist’s identity/race/culture), about your experiences with your identity/race/culture?

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11/23/23

Traumatic Memory & Best Practices for EMDR: Resource Development, Expectations and Setting Clients up for Effective EMDR Treatment

Daphne Fatter, Ph.D. (She/Her) Licensed Psychologist IFS Certified & IFS Consultant EMDRIA Certified & EMDRIA Consultant in Training (CIT)

Learning Objectives 1. Describe in client-friendly terms what happens in the brain during EMDR to help set realistic treatment expectations. 2. Identify at least 2 indicators of client readiness for EMDR trauma processing. 3. Apply at least 2 interventions to use during Phase 2 to support client’s accessing resilience. 4. Utilize 2 ways to track dissociation in session. 5. Integrate the “Identity, Race, Culture Interview” into Phase 1 & Phase 2.

What is Trauma Processing? Ø Desensitization to traumatic memory + feelings & physical sensations associated with re-experiencing memory. Ø Construction of new meaning –> a more adaptive view of self, others and traumatic events. Ø Integrating both rational and linguistic processes to raw unmetabolized fragmented traumatic experiential data. (Courtois & Ford, 2016)

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What is Trauma Processing? • Structured process: Client can make an informed choice, give informed consent and have a sense of what will happen next in process(within reason). • Focus on the hardest most painful parts of the traumatic event (APA, 2017). Ø Indicator of resolution = trauma narrative is coherent and fits into larger life narrative. Ø Survivor can reflect on it and know experientially its in past and can be “lived with”.(Paivio & Pascual-Leone, 2010) (Courtois & Ford, 2016)

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Accessing Traumatic Memory Networks & What Happens When a Client is Triggered

Traumatic memory is stored in isolated fragments of sensory perceptions, affective states and sensory-motor levels (Nemiah, 1998; van der Kolk & van der Hart, 1991). Visual Images Emotions

Beliefs Traumatic Memory

Smells

Sounds Tastes

Body Sensations Body Postures & Movements

Traumatic Memories vs Non-traumatic Memories

Adapted from van der Kolk et al., 1994; van der Kolk & Fisler, 1995, Van der Kolk et al., 1996.

Traumatic Memories Stored as raw sensorimotor data in forms of smells, sounds, images, body sensations, emotions.

Non-traumatic Memories Integrated into consciousness with sensory experience intact (sensory exp. Is not stored separately).

Not connected to language and not “encoded” with context.

Context to Memory =Meaningful narrative. Beginning, middle and end to story.

Managing Triggers & Importance of Stabilization in Phase 1 & 2 Traumatic Memories Stored at High Arousal

Arousal Level due to Everyday Stress

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Engaging The Left & Right Hemisphere (Fisher, 2017)

• We compartmentalize under stress -> • Right brain dominant through childhood (Cozolino, 2002; Schore, 2001). • Left brain development is slow over first 18 years of life. • Corpus callosum – develops by age 12. • Tiecher (2004) found correlation between a history of neglect and/or abuse with under-development of corpus callosum compared with controls. • Trauma => independent development of right and left hemispheres = “two brains”, instead of one integrated brain (Gazzaniga, 2015; Fisher, 2017).

Trauma = “Two Brains” (Gazzaniga, 2015; Fisher, 2017)

Left Brain – “The Storyteller”

Right Brain – “The Truth Teller”

o Autobiographical Memory + Acquired Knowledge

o Implicit Memory (and sensory information)

o Tendency to grasp “gist” of situation.

o “does not forget” non-verbal aspects of experience.

o Making inferences that fits well with general schema of situation and throws out the rest.

o Only identifies the original information - does not interpret it.

o Ability to encode with language doesn’t mean o Without effective communication via corpus its more accurate - makes it easier to process callosum, split-brain researchers observed information. that left might have no memory of right’s emotion-driven actions.

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.

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• “Trauma comes back as a reaction, not a memory.” “We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present. • Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.” ― Bessel A. van der Kolk, MD. (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

EMDR “The information processing system is adaptive when it is activated” (Shapiro, 2018, p 28) Traditional 3-pronged approach (Shapiro, 2018): • Past • Present • Future • Ancestral: Proposed 4th prong (Dr. Karen Alter-Reid, 2023); Generational/Legacy-attuned protocols (Robinson, 2023). 13

How Does EMDR Work? (see Landin-Romero et al., 2018 for review)

Mechanism of change for EMDR is still in its infancy & an integrative explanation is proposed due to multiple processes occurring in EMDR: • Working Memory Hypothesis: 1) Dual attention task of bilateral stimulation taxes working memory -> decreasing level of arousal associated with traumatic memory. 2) Increases access to episodic memories. 3) Activates working memory which facilitates a process of accessing traumatic memories in a tolerable way. (Jeffries & Davis, 2013; Landin-Romero et. at.,2018) • Mimics REM sleep theory: ‘kick starts’ processes active during REM sleep. • Intra-hemispheric changes in right hemisphere and interhemispheric changes between right and left hemispheres. • Multiple changes in the brain: Neuroimaging research shows after EMDR increase in hippocampal volume, increased activity in left frontal lobe and the anterior cingulate gyrus (in limbic system)-> increased emotion regulation; traumatic memories experienced as no longer threatening.

How To Communicate Realistic Expectations ØDecrease emotional and sensorimotor reactivity to traumatic memories:

• Trauma processing does not take the memory away. • The memory may not become neutral, but no longer experienced as currently a threat. • Meaning making can change; client’s relationship to memory can change. • If client’s don’t have memories of an event, cannot promise that clients will discover a memory.

ØDevelop a personal understanding of their life that is:

• Coherent (e.g. can be put into words) • Has a logical sequence of client’s feelings, thoughts and actions during traumatic event. • Includes a theory/sense of understanding of motives & actions/inactions of others (other victims, caregivers who helped or didn’t protect or help, bystanders, community response) & how this impacted client’s experience. (Courtois & Ford, 2016) Copyright © 2023 Daphne Fatter, Ph.D.

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Two Indicators of Client Readiness • Personal resources: (e.g. skills taught via STAIR, DBT, etc.)

• Self-soothing skills (breath, exercise, self-talk, faith, dance) • Containment skills (e.g. safe place imagery)

• Support system: Is client access support in ways that align with their culture? • Empirical evidence shows biological and psychological benefit of social support that is provided in a culturally congruent manner (Taylor et al., 2007).

• #1 State Change: Can the client change states?

• Timing of treatment. • Medication is appropriately being managed and serving client (no benzos).

• #2 Is the client able to practice state change on their own in between sessions? • 5 tried and true coping skills/sequence of 5 skills.

Factors that Contribute to Early Termination • From recent systematic reviews and meta-analysis, drop out rates for PTSD treatment = 18% (Lewis et al., 2020b) to 20% (Varker et al., 2021). • Trauma processing therapies with a trauma-focus were significantly associated with greater dropout rates (18%). • Drop out rate is higher for military and veteran populations compared to civilian populations (Varker et al., 2021). • No evidence that therapy in group format had greater dropout rate (Lewis et al., 2020b). • Estimated rate of reported side effects is between 3% and 15% • Similar magnitude for pharmacotherapy side effects (Linden, 2012) • Main reasons therapists did not use exposure-based trauma-focused intervention: • Therapists concerns about tolerability and dropout were among the main reasons (Becker, Zayfert,& Anderson, 2004).

Setting Up Trauma Processing for Success o Shared decision making (APA, 2017; APA, 2021a; Bisson et al., 2019; Hamblen, et al., 2019; Harik et al., 2016) o o

Hear all the available treatment options. Specifically know about treatment effectiveness and side effects.

o Guidelines for Evidenced-Based Practice (APA, 2021) & International Society for Traumatic Stress Studies (Bisson et al., 2019): o Shared decision making between client and therapist. o Shared decision making across treatment providers.

o Client being able to choose -> may improve retention because of self-selection (Lewis et al., 2020b; Harik et al., 2016). o Individualized treatment plans. There are many trauma models that are evidenced-based – o Trauma Treatment is not ‘one size fits all; (Hamblen, et al., 2019; Lewis et al., 2020b).

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Setting Up EMDR for Success • Low drop out rate (esp. compared to other exposure- based models like prolonged exposure therapy) (See Wilson et al., 2018 for review) • EMDR therapy is more effective when (Wilson et al., 2018): • Delivered by more experienced therapists (Chen et al., 2015) • When sessions lasted more than 60 min (Chen et al., 2014).

Informed consent (APA, 2017)

• THIS IS THE #1 Most Important Initial Step in Trauma Processing! • Client can stop at any time including midsession. • Know risks, side effects and benefits of procedure. • What to expect emotionally – a short term increase of PTSD symptoms is normal. • Plan for how to manage arousal during processing and in between sessions. • Procedure for how to stop during processing. • Attend to therapeutic relationship. Copyright © 2023 Daphne Fatter, Ph.D.

Cultural Considerations Before Trauma Processing • Layers of Trauma: Traumatic Event + Response by Family/Support System + Shame. • Find out from your client: • Meaning of traumatic event? Who knows in their support system? How did family react? • Identify outside resources/referrals that are culturally appropriate? • What does it mean that they are seeking help regarding trauma according to culture? • What does it mean to address trauma directly in therapy according to cultural beliefs? (Brown, 2008; Drozdek & Wilson, 2007; Dutton,1998; Hendricks, 2015) Case Examples: “You will become tainted”; Transplant; After-life.

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Intentionally Using Language • Language “code switching” (alternating between 2+ languages) in trauma processing has been shown to help client: • More fully express emotions. • More likely to occurs when emotions increase, heightened when talking about traumatic event and feelings of shame. • Can be strategically used by therapist for titration (distancing or increasing intensity). (Dewaele & Costa, 2013)

Treatment Recommendations: PTSD & Multiple Marginalized Identities (Williams et al.,, 2023)

• Consider that the experience of PTSD clients with multiple marginalized identities qualitatively differs than the experience of trauma survivors from dominant cultural groups. • Be aware that clients with more marginalized identities are more likely to have trauma symptoms. • Greater intersectionality is more likely to contribute to greater cumulative impact of traumatic stress. • Assess and ask specifically about PTSD related to discrimination.

Treatment Recommendations: PTSD & Multiple Marginalized Identities • May need longer time to establish rapport and working alliance in treatment, given collective historical relationship with medical system and medical providers (Ashley & Lipscomb, 2023). • For transgender, non-binary and gender diverse clients, interactions with the medical system and providers can be on-going source of trauma (Chang et al., 2018). • In treatment plan (Bartlett, et al., 2023; Williams et al., 2023): • Tailor coping skills given the client's unique intersectional stressors + empowerment-oriented approaches that support client accessing social community capital. • E.g. communal support systems, peer groups, mentorship.

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Including Partners & Family in Trauma Treatment • Preliminary research suggests that including family briefly in traumafocused individual therapy is helpful for both clients, their family members (Thompson-Hollands, et al., 2021) and qualitatively valuable to treatment per clinicians (Thompson-Hollands, et al., 2022). • Brief Family Intervention for PTSD: 2 one-hour sessions a week a part before beginning PE or CPT (Trauma Processing). • Limitations: Currently only one study on clients & their family; One study on providers experiences; Need for randomized controlled trial research and need for training to clinicians to conduct family therapy/inclusive sessions with family member. • Recommended particularly for clients of interdependent cultural groups that value family and the community with regards to one’s sense of self (Heim, Karatzias, & Maercker, 2022). Copyright © 2023 Daphne Fatter, Ph.D.

EMDR: 8 Phases of Treatment 1. History/Treatment Planning 2. Client Preparation: Resource Development 3. Assessment Phase: Ø “Three-pronged” Approach: Past, present and future Ø Ancestral: Proposed 4th prong (Dr. Karen Alter-Reid, 2023) Ø Negative cognition, validity of cognition, emotions/SUDS/body 4. Desensitization & Reprocessing: Ø Dual attention. 5. Installation of Positive Cognition 6. Body Scan 7. Closure 8. Reevaluation (Korn, 2009; Shapiro, 2018) Copyright © 2023 Daphne Fatter, Ph.D.

Phase 1 • Assessing for Dissociation • Implement the “Identity, Culture, Race” Interview (Multiple Contributors, 2021) • Clinical Assessment Options

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Resources For Dissociation • Dissociation Experiences Scale (DES): Screener to assess if clients are appropriate candidates for EMDR. • High Levels of Dissociation = scores of 30 or more, then use clinical interview or other assessment measures (e.g. MIDD). • Recommended to use with every client (Marich, 2023) • Clinical Resource: “Dissociation Made Simple” by Jamie Marich, 2023

2 Ways to Track Dissociation in Session • Back of the Head (Knipe, 2015)

• Presences Scale (Jennifer Marchand, 2023)

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Body as Container (Levine, 2018)

1. Take right hand, put it under left arm (on side of heart). 2. Take the left hand on the right shoulder. 3. Notice what goes on inside the body (client becomes aware that body is container for our feelings) 4. Keep doing this until notice energy shift. Especially helpful for dissociation symptoms

“Hands to Forehead & Chest, then Chest & Belly” (Levine, 2018)

1. Put one hand on your forehead and the other hand on your chest. 2. Can do this with eyes open or closed. 3. Feel what goes on between the hands – keep there until they notice an energy shift. 4. Then take hand from forehand (keeping other hand on chest), and place hand on belly (bellow belly button). 5. Keep the hands here until notice energy shift and feeling calm. Especially helpful for dissociation symptoms Copyright © 2023 Daphne Fatter, Ph.D.

Assessment Tools for CPTSD • The International Trauma Questionnaire (ITQ) (Cloitre, et al., 2018; Cloitre, 2021): Self-report measure, freely accessible online, convenient. • Validated across different populations and most thoroughly investigated (Seiler, et al., 2023).

If inappropriate to use self-report measures, can use interview-based assessments: • International Trauma Interview (ITI): clinician-administered diagnostic interview to assessment of ICD-11 PTSD and CPTSD (Gelezelyte, et al., 2022; Roberts et al., 2018) • Symptoms of Trauma Scale (SOTS) (Ford et al., 2015): a 12-item, clinician-rated, interview-based measure. • Complex PTSD Item Set additional to the Clinician Administered PTSD Scale (COPISAC) (Lechner-Meichsner, & Steil, 2021): Additional questions to the CAPS; using the Life Events Checklist is also recommended. Copyright © 2023 Daphne Fatter, Ph.D.

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Assessment for Discrimination & Oppression-based Trauma • Trauma Symptoms of Discrimination Scale (TSDS) (Williams et al., 2018) • 21 item self-report measure assesses trauma symptoms across multiple types of discrimination experienced:

• uncontrollable arousal • feelings of alienation • worries about future negative events • perceiving others as dangerous

• “For example if you’ve experienced discrimination due to your racial/ethnic background and gender, attach a percentage indicating how much of each you have experienced (i.e., Racial/Ethnic = 70%, Gender = 30%) (Williams et al., 2018)”.

Assessments for Racial Trauma Clinician-Administered: Uconn Racial/Ethnicity Stress & Trauma Stress Scale (UnRESTS) (Williams, Metzger, Leins, & DeLapp, 2018): • Racial and Ethnic Identity Development • Experiences of Direct Overt Racism • Experiences of Racism by Loved Ones • Experiences of Vicarious Racism • Experiences of Covert Racism • Racial Trauma Assessment Self Report scales: Ø Race Based Trauma Stress Symptom Scale (Carter et al, 2013) Ø Racial Trauma Scale (Gallo, et al., 2020) Ø General Ethnic Discrimination Scale. (Landrine, et. al., 2006). • Clinical Resource: http://www.mentalhealthdisparities.org/trauma-research.php Copyright © 2023 Daphne Fatter, Ph.D.

Systemic & Oppression-based Traumas Racial traumas (Archer, 2021; Ashley & Libscomb, 2023): • Trauma processing can potentially activate powerlessness and helplessness associated with racial trauma and other oppression-based traumas. • May need to assess if therapy appropriately addressed other oppression-based memories that are not the presenting problem but may re-enforce feelings, body sensations and/or internalized beliefs. • Being aware that working with racial trauma – targeted traumatic experience is in past, but threat/hypervigilance that it could happen again is normal and should not be pathologized (Ashley & Libscomb, 2023; Sue ,2010). Copyright © 2023 Daphne Fatter, Ph.D.

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Phase 2: Resource Development • Strengthening Cultural Resilience Resources • Strengthening Relational Resources (Parnell, 2008)

Applying a Community Cultural Wealth Lens to Phase 2

Resource Development: Integrating Culturally-Based Strengths (Nickerson, 2023a; Levis, & Siniego, 2017; Levis, 2017; Yosso, 2005)

• EMDR Lens: • Identify & strengthening individual resources with focus on connection with community (Levis, & Siniego, 2017; Levis, 2017) • Can strengthen resources for clients coping with current challenges (Nickersona, 2023) Practical Application:

Therapist can help client identify resources, can strengthen through RDI during phase 2 via EMDR. E.g. “Where do you feel that in your body? Slow BLS Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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Resource Development: Integrating Culturally-Based Strengths (Nickerson, 2023a; Levis, & Siniego, 2017; Levis, 2017; Yosso, 2005)

• Social Capital: Current or previous peer, mentor and social connections. • Positive experiences of inclusion, belonging or connection. Are there groups, gatherings or celebrations that create a sense of support? • Linguistic Capital: Understanding in-group communication (non-verbals, formal/informal context) to foster connection and communication; bilingualism, multilingualism; may be rich in ways to express/songs/stories/story-telling. • What skills, strengths, and intuition have helped you navigate language differences; Have helped you communicate and connect with others? • Familial Capital: Any family connection, cultural or communal support; these may have potentially been left behind via differentiating, assimilation or acculturation. • Positive experiences related to one’s own cultural identity; Sense of belonging; Spiritual resources including ancestors; Generational Resources. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Resource Development: Integrating Culturally-Based Strengths (Nickerson, 2023a; Levis, & Siniego, 2017; Levis, 2017; Yosso, 2005)

• Navigational Capital: acknowledges skills learned through collective and communal wisdom navigating cultural and systemic challenges. • What skills and strengths have helped you navigate and negotiate living in two worlds and/or maneuver through systems that are unfriendly or dangerous? • Resistance Capital: Accesses examples and experiences of one’s people advocating for social justice and equity. • Who are your role models for advocating for social justice and equity? • Are there people for whom you are a role model or whose dreams depend on you continuing to walk this path? • Aspirational Capital: Hopes and Dreams of one’s people->activate sense of purpose and resiliency. • During your hardest times navigating challenges associated with your identity/race/culture, how did you keep going? What made you so determined to survive? Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without 41 Permission

Practice Time!

Please get into Pairs.

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Practice Choices (From Identity, Race, & Cultural Interview) • “Have you ever felt significant affirmation and belonging because of your identity/race/culture? Are there groups, gatherings, or celebrations (including places of worship, traditions or festivals) that create a sense of social support for you?” (Social Capital) • “What skills, strengths, or intuition have allowed you to navigate any language differences, negotiate living in two works and/or maneuver through systems that are unfriendly, dangerous, and full of hurdles for those not in the dominant culture?” (Cultural Intuition, Navigational & Linguistic Capital) • “During your hardest times navigating challenges associated with your identity/race/culture, how did you keep going? Are there any spiritual/religious beliefs and practices and/or people that helped you endure and make meaning of difficulties” (Aspirational & Spiritual Capital)

Slow Tapping & Relational Resources

(Adapted from Parnell, 2008)

• Resource Team: Real or imagined, animals, figures from history, movies or from books, ancestors, generational resources. • Protective Figure • Nurturing Figure • Wise Figure/Inner Wisdom Figure • Can use figure one at a time or all together à Tap to strengthen. • “What 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.” Copyright © 2023 Daphne Fatter, Ph.D.

Current Telehealth EMDR Research Ø Research supports its effectiveness for telehealth with CPTSD (Bongaerts et al., 2021; Bongaerts et al. 2022). Ø “The most important predictor of the SUD decrease was the type of bilateral stimulation used in eEMDR sessions. Eye movements resulted in significantly greater SUD reductions than tapping.” (Mischler, et al., 2021). Ø Using the Immediate Stabilization protocol used for healthcare workings during COVID-19: Tarquinio, et al. (2020). Ø Showed the effectiveness of EMDR-Integrative Group Treatment Protocol for Ongoing Traumatic Stress Remote (EMDR-IGTP-OTS-R) in decreasing PTSD, depression, and anxiety symptoms in healthcare professionals working in hospitals during the Covid-19 pandemic in Puebla, Mexico. (Perez, et al., 2020) Ø Clinical Resource: https://www.emdria.org/publications-resources/practice-resources/online-emdrtherapy-resources/

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Used with permission from EMDRIA

References

Alter-Reid, K. (2023), “Interrupting and Healing Trans-generational Trauma with EMDR Therapy”. Presented at the 2023 EMDRIA Conference, Washington D.C., August 2023. American Psychological Association (2021). APA Guidelines on Evidence-Based Psychological Practice in Health Care. Retrieved May 26, 2023 from https://www.apa.org/about/policy/psychologicalpractice-health-care.pdf American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. Retrieved May 26, 2023. https://www.apa.org/ptsd-guideline Archer, D. (2021). Anti-Racist psychotherapy: Confronting systemic racism and healing racial trauma. Each One Teach One Publications. Ashley. W. & Libscomb, A. (2023) Strategies for implementation of an anti-oppressive, antiracist, intersectional lens in EDR therapy with Black clients. In Nickerson, M. (Ed.) (2023). Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. Springer Publishing Company; 2nd edition.

References Bartlett A, Faber S, Williams M, Saxberg K. Getting to the Root of the Problem: Supporting Clients With Lived-Experiences of Systemic Discrimination. Chronic Stress. 2022;6. doi:10.1177/24705470221139205 Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277–292. doi: 10.1016/S0005-7967(03)00138 Bisson JI, Berliner L, Cloitre M, Forbes D, Jensen TK, Lewis C, Monson CM, Olff M, Pilling S, Riggs DS, Roberts NP, Shapiro F. (2019). The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of PTSD: Methodology and Development Process. Journal of Traumatic Stress, 32, 475-483. Bongaerts, H. Voorendonk, E. M., van Minnen, A., & de Jongh, A. (2021). Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth. European Journal of Psychotraumatology, 12(1), 1860346. Open access: http://dx.doi.org/10.1080/20008198.2020.1860346 Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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References Bongaerts, H., Voorendonk, E. M., van Minnen, A., Rozendaal, L., Telkamp, B. S. D., & de Jongh, A. (2022). Fully remote intensive trauma-focused treatment for PTSD and complex PTSD. European Journal Psychotraumatology, 13(2): 2103287. Open access: https://doi.org/10.1080/20008066.2022.2103287

Bremner, J. D. (2006). Traumatic stress: effects on the brain. Dialogues Clin Neuroscience, 8(4):445-61. doi: 10.31887/DCNS.2006.8.4/jbremner. PMID: 17290802; PMCID: PMC3181836. Brown, L. S. (2008). Cultural Competence in Trauma Therapy: Beyond the Flashback. American Psychological Association. Carter, R. T., Mazzula, S., Victoria, R., Vazquez, R., Hall, S., Smith, S., Sant-Barket, S., Forsyth, J., Bazelais, K., & Williams, B. (2013). Race-Based Traumatic Stress Symptom Scale (RBTSSS) [Database record]. APA PsycTests. Chang, S. C., Singh, A., & Dickey, L. M. (2018). A clinician's guide to gender-affirming care: Working with transgender & gender nonconforming clients. New Harbinger Publications, Inc. Chen Y. R., Hung K. W., Tsai J. C., Chu H., Chung M. H., Chen S. R., et al.. (2014). Efficacy of eye-movement desensitization and reprocessing for patients with posttraumatic-stress disorder: a meta-analysis of randomized controlled trials. PLoS ONE 9:e0103676. 10.1371/journal.pone.0103676 Chen L., Zhang G., Hu M., Liang X. (2015). Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: systematic review and meta-analysis. J. Nervous Mental Dis. 203, 443–451. 10.1097/NMD.0000000000000306 Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

References Chopra, M. P., Zhang, H., Pless Kaiser, A., Moye, J. A, Llorente, M. D., Oslin, D. W., & Spiro, A. (2016). PTSD is a chronic, fluctuating disorder affecting the mental quality of life in older adults. The American Journal of Geriatric Psychiatry : Official Journal of the American Association for Geriatric Psychiatry, 22(1), 86–97. doi:10.1016/j.jagp.2013.01.064 Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956 Cloitre, M., Brewin, C. R., Bisson, J. I., Hyland, P., Karatzias, T., Lueger-Schuster, B., . . . Shevlin, M. (2020). Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: Response to Achterhof et al., (2019) and Ford (2020). European Journal of Psychotraumatology, 11, 1739873. doi:10.1080/20008198.2020.1739873 Cloitre, M. (2021) Complex PTSD: assessment and treatment. European Journal of Psychotraumatology, 12:sup1, 1866423, DOI: 10.1080/20008198.2020.1866423 Courtois, C. A. & Ford, J. D. (2016). Treatment of complex trauma: A Sequenced, relationship-based approach. The Guilford Press.

References Dewaele, J.-M., & Costa, B. (2013, December 1). Multilingual Clients’ Experience of Psychotherapy. Language and Psychoanalysis, 2(2), 31-50. https://doi.org/https://doi.org/10.7565/landp.2013.005 Drozdek, Boris, & Wilson, John P. (Eds.) (2007). Voices of Trauma: Treating Psychological Trauma Across Cultures. Springer. Dutton, M.A. (1998). Cultural issues in trauma treatment. Centering, 3(2). Fisher, J. (2017). Healing the Fragmented Selves of Trauma Survivors: Overcoming Self-Alienation. Routledge: New York, NY. Ford, J. D., Mendelsohn, M., Opler, L. A., Opler, M. G., Kallivayalil, D., Levitan, J., Pratts, M., Muenzenmaier, K., Shelley, A. M., Grennan, M. S., & Lewis Herman J. (2015). The Symptoms of Trauma Scale (SOTS): An Initial Psychometric Study. J Psychiatr Pract,21(6):474-83. doi: 10.1097/PRA.0000000000000107. PMID: 26554331; PMCID: PMC4643404. Jeffries, F.W. & Davis, P. (2013). What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review. Behavioral Cognitive Psychotherapy, 41(3): 290–300. Published online 2012 Oct 29. doi: 10.1017/S1352465812000793 Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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References Gallo J, Sharif N, Gran-Ruaz S, Strauss D, & Williams M. (2020). The racial trauma scale: seeing trauma in colour. Poster session presented at: Association for Behavioral and Cognitive Therapies - 54th Annual Convention; 2020 Nov 19–22; Philadelphia, PA. Gazzaniga, M. S. (2015). Tales from both sides of the brain: a life of neuroscience. New York: HarperCollins. Gelezelyte, O. Roberts, N. P., Kvedaraite, M., Bisson, J. I., Brewin, C. R. Cloitre, M., et. Al., 2022) Validation of the International Trauma Interview (ITI) for the Clinical Assessment of ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) in a Lithuanian Sample, European Journal of Psychotraumatology, 13:1, DOI: 10.1080/20008198.2022.2037905 Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., Megnin-Viggars, O., Forbes, D., Riggs, D. S., & Schnurr, P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56(3), 359– 373. https://doi.org/10.1037/pst0000231

References Harik, J. M., Hundt, N. E., Bernardy, N. C., Norman, S. B., & Hamblen, J. L. (2016). Desired involvement in treatment decisions among adults with PTSD symptoms. Journal of Traumatic Stress, 29, 221-228. PILOTS: 44824 Heim, E., Karatzias, T., & Maercker, A. (2022). Cultural concepts of distress and complex PTSD: Future directions for research and treatment. Clinical Psychology Review, 93, 1– 14. https://doi.org/10.1016/j.cpr.2022.102143 Hendricks, A. (2015). Culturally Modified Trauma-Focused Cognitive Behavioral Therapy for Latino Children and Families. http://www.cibhs.org/sites/main/files/fileattachments/tues_1pm_granada_tfcbt_ebp_hendricks.pdf Hill, M.D. (2019). Adaptive Information Processing Theory: Origins, Principles, Applications, and Evidence. Journal Evidenced-Based Social Work, 17(3):317-331. doi: 10.1080/26408066.2020.1748155. Epub 2020 Apr 24. PMID: 32420834. Knipe, J. (2015). EMDR toolbox: Theory and treatment of complex PTSD and dissociation. Springer Publishing Co.

References Korn, D. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research, Vol. 3, No. 4, pp. 264-278. Landin-Levis, R. V., & Siniego, L. B. (2017). An Integrative Framework for EMDR Therapy as an AntiOppression Endeavor. In Nickerson, M. I. (Ed.), Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols (pp. 79-96). New York, NY: Springer Publishing Co. Linden, M. (2012). How to define, find and classify side effects in psychotherapy: From unwanted events to adverse treatment reactions. Clinical Psychology and Psychotherapy, Published Online in Wiley Online Library. doi: 10.1002/cpp.1765 Levine, P. A. (2018). Polyvagal Theory & Trauma. In Clinical Applications of the Polyvagal Theory: The emergence of polyvagal-informed therapies. p. 3-26. Porges, S. W. & Dana, D. (Eds). New York: W.W. Norton & Company. Levis, R. V. (2017). Placing Culture at the Heart of EMDR Therapy. In Nickerson, M. I. (Ed.), Cultural Competence and Healing Culturally-Based Trauma with EMDR Therapy: Innovative Strategies and Protocols (pp. 97-112). New York, NY: Springer Publishing Co.

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References Landrine, H., Klonoff, E. A., Corral, I., Fernandez, S., & Roesch, S. (2006). Conceptualizing and measuring ethnic discrimination in health research. Journal of Behavioral Medicine. 29:79–94. Lechner-Meichsner, F., & Comtesse, H. (2022). Beliefs About Causes and Cures of Prolonged Grief Disorder Among Arab and Sub-Saharan African Refugees. Frontiers in psychiatry, 13, 852714. https://doi.org/10.3389/fpsyt.2022.852714 Lewis, C. Roberts, N. P. Gibson, S. & Bisson, J. I. (2020b) Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis, European Journal of Psychotraumatology, 11:1, DOI: 10.1080/20008198.2019.1709709 Marchand, J. (2023), “Moving Toward a Sustainable & Responsive EMDR Telehealth Practice (Post at the 2023 EMDRIA Virtual Conference, Spring 2023.

COVID).” Presented

Maxfield, L. (2019). A clinician’s guide to the efficacy of EMDR therapy. Journal of EMDR Practice and Research [Editorial], 13(4), 239-246. http://dx.doi.org/10.1891/1933-

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References Mischler, C., Hofmann, A., Behnke, A., Matits, L., Lehnung, M., Varadarajan, S., Rojas, R., Kolassa, I-T., & Tumani, V. (2021). Therapists’ experiences with the effectiveness and feasibility of videoconference-based eye movement desensitization and reprocessing. Frontiers in Psychology: Psychology for Clinical Settings, 748712. Nemiah, J. C. (1998). Early concepts of trauma, dissociation, and the unconscious: Their history and current implications. In J. D. Bremner & C. R. Marmar (Eds.), Trauma, memory, and dissociation (pp. 1–26). American Psychiatric Association. Nickerson, M. (2023). Opening the Door: Exploring social and cultural experiences and building resources – EMDR phases 1 and 2. In Nickerson, M. (Ed.) Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols, (pp. 66-83). Springer Publishing Company; 2nd edition. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

References Novo Navarro P, Landin-Romero R, Guardiola-Wanden-Berghe R, Moreno-Alcázar A, ValienteGómez A, Lupo W, García F, Fernández I, Pérez V, Amann BL. (2018). 25 years of Eye Movement Desensitization and Reprocessing (EMDR): The EMDR therapy protocol, hypotheses of its mechanism of action and a systematic review of its efficacy in the treatment of post-traumatic stress disorder. Rev Psiquiatr Salud Ment (Engl Ed). Apr-Jun;11(2):101-114. English, Spanish. doi: 10.1016/j.rpsm.2015.12.002. Epub 2016 Feb 11. PMID: 26877093. Pagani M, Castelnuovo G, Daverio A, La Porta P, Monaco L, Ferrentino F, Chiaravalloti A, Fernandez I, Di Lorenzo G. (2018). Metabolic and Electrophysiological Changes Associated to Clinical Improvement in Two Severely Traumatized Subjects Treated With EMDR-A Pilot Study. Front Psychol. Apr 16;9:475. doi:10.3389/fpsyg.2018.00475. PMID: 29713297; PMCID: PMC5911467 Penailillo, C. C. (2022). Clinical considerations when treating immigration-based trauma within Latinx clients using EMDR therapy. In M. Nickerson (Ed.), Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy (pp. 259-270). New York, NY: Springer Publishing Company. Parnell, Laurel. (2008). Tapping In: A Step-by-Step Guide to Activating Your Healing Resources Through Bilateral Stimulation. Sounds true.

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References Perez, M. C., Estevez, M. E., Becker, Y., Osorio, A., Jarero, I., & Givaudan, M. (2020). Multisite randomized controlled trial on the provision of the EMDR integrative group treatment protocol for ongoing traumatic stress remote to healthcare professionals working in hospitals during the Covid-19 pandemic. Psychology and Behavioral Science, 15(4), 555920. DOI: 10.19080/PBSIJ.2020.15.555920. Petzold, M & Bunzeck, N. (2022). Impaired episodic memory in PTSD patients - A meta-analysis of 47 studies. Front Psychiatry,13:909442. doi: 10.3389/fpsyt.2022.909442. PMID: 36245884; PMCID: PMC9553990. Pitts, B.L., Eisenberg, M.L., Bailey, H.R. et al. (2022). PTSD is associated with impaired event processing and memory for everyday events. Cogn. Research 7, 35. https://doi.org/10.1186/s41235-022-00386-6 Pless Kaiser, A., Cook, J. M., Glick, D.M,. Moye, J. (2019). Posttraumatic Stress Disorder in Older Adults: A Conceptual Review. Clin Gerontol.,42(4):359-376. doi: 10.1080/07317115.2018.1539801. Epub 2018 Nov 13. PMID: 30422749; PMCID: PMC6666306. Roberts, N. P., Cloitre, M., Bisson, J., & Brewin, C. R. (2018). International Trauma Interview (ITI) for ICD-11 PTSD and complex PTSD (Test Version 3.1). Retrieved May 23, 2023, from PTSD Research Quarterly (2021),32(2), 9. https://www.ptsd.va.gov/publications/rq_docs/V32N2.pdf

References Robinson, N. S. (2023). Legacy attuned emdr therapy: Toward a coherent narrative and resilience. p. 383-391. In Nickerson, M. (Ed.) Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. Springer Publishing Company; 2nd edition. Romero, R., Moreno-Alcazar, A., Pagani, M., Amann, B.L. (2018). How does eye movement desensitization and reprocessing therapy work? A systematic review on suggested mechanisms of action. Frontiers in Psychology,13(9), 1395, 1-23. Seiler, N., Davoodi, K., Keem, M. & Das, S. (2023) Assessment tools for complex post traumatic stress disorder: a systematic review, International Journal of Psychiatry in Clinical Practice, DOI: 10.1080/13651501.2023.2197965 Shapiro, R. (Ed.) (2005). EMDR Solutions: Pathways to healing. New York, NY: Norton and Norton Company. Shapiro F. The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. Perm J. 2014 Winter;18(1):71-7. doi: 10.7812/TPP/13-098. PMID: 24626074; PMCID: PMC3951033 Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols and Procedures.(3rd edition). The Guilford Press.

References Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons Inc. Tarquinio, C., Brennstuhl, M., Rydberg, J. A., Bassan, F., Peter, L., Tarquinio, C. L., & . . . Tarquinio, P. (2020). EMDR in telemental health counseling for healthcare workers caring for COVID-19 patients: A pilot study. Issues in Mental Health Nursing, published online. Taylor, S. E., Welch, W. T., Kim, H. S., & Sherman, D. K. (2007). Cultural differences in the impact of social support on psychological and biological stress responses. Psychological Science, 18(9), 831–837. https://doi.org/10.1111/j.1467- 9280.2007.01987.x Thompson-Hollands, J., Rando, A. A., Stoycos, S. A., Meis, L. A., & Iverson, K. M. (2022). Family Involvement in PTSD Treatment: Perspectives from a Nationwide Sample of Veterans Health Administration Clinicians. Administration and policy in mental health, 49(6), 1019– 1030. https://doi.org/10.1007/s10488-022-01214-1

11/23/23

References van der Kolk, B. A., & van der Hart, O. (1991). The Intrusive Past: the Flexibility of Memory and the Engraving of Trauma. American Imago, 48(4), 425–454. http://www.jstor.org/stable/26303922 van der Kolk, (1994). The body keeps score: Memory and the emerging psychobiology of post traumatic stress. Harvard Review of Psychiatry, 1, pp. 253-265. van der Kolk & Fisler (1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. Journal of Traumatic Stress, 8, pp. 505-525. van der Kolk, B.A., McFarlane, A., Weisaeth, L., (eds.) (1996). Traumatic Stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press: 1996. van der Kolk, B. A. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books.

References Varker, T., Jones, K. A., Arjmand, H. A., Hinton, M., Hiles, S. A., Freijah, I., ... & O'Donnell, M. (2021). Dropout from guideline-recommended psychological treatments for posttraumatic stress disorder: A systematic review and meta-analysis. Journal of Affective Disorders Reports, 4, 100093. Williams, M. T., Printz, D., & DeLapp, R. C. T. (2018). Assessing racial trauma in African Americans with trauma symptoms of discrimination scale. Psychol Violence;8(6):735–747. 10.1037/vio0000212

the

Williams, M., Osman, M., & Hyon, C. (2023). Understanding the Psychological Impact of Oppression Using the Trauma Symptoms of Discrimination Scale. Chronic Stress (Thousand Oaks),7:24705470221149511. doi: 10.1177/24705470221149511. PMID: 36683843; PMCID: PMC9850126. Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., & Kiernan, M. D. (2018). The Use of EyeMovement Desensitization Reprocessing (EMDR) Therapy in Treating Post-traumatic Stress Disorder-A Systematic Narrative Review. Frontiers in psychology, 9, 923. https://doi.org/10.3389/fpsyg.2018.00923 Yosso, T. J. (2005). Whose culture has capital? A critical race theory discussion of community cultural wealth. Race, Ethnicity, and Education, 8(1), 69-91. https://doi.org/10.1080/1361332052000341006 Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

Troubled & disordered a.achments and the current

Youth Mental Health Crisis

Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

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

making sense of the

Youth Mental Health Crisis

Youth Mental Health Crisis - G. Neufeld

THEORY:

Jack Hirose Seminars Fall, 2023

ARGUMENT for MENTAL HEALTH being ROOTED in ATTACHMENT

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

EVIDENCE:

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

mental health

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

... care

Attachments are specifically structured for giving & receiving CARE

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

PROVIDING CARE

SEEKING CARE

dependent insNncts dependent instincts • for an invitation to exist

alpha instincts

• for contact and connection • for sameness & belonging

• for warmth & love • for recognition • for significance

seeking

• to get one’s bearings

PROVID

ING

• for safety and comfort

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

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

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

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

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

mental health

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

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

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

ar yc a d e ve loss of lo d on

mov ing

STRESs

threats to iden tity

on adopN

sec rets

ling er sib h t o n a ST

DIVORCE

E NT US RETIREME AB

CHANGE

LO ng bei resi d sch enNal ool

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

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

d by ... not recognize

t isola tion g ngin belo n ot

ced repla

by ...

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

closure separa$on-triggered

PURSUIT

ALARM

FRUSTRATION

cau$on

change

Youth Mental Health Crisis - G. Neufeld

Stress Response

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

Jack Hirose Seminars Fall, 2023

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

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

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

Stress Response

s Resilience Response lem b ro hp

G N I L

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

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

M EE

N TIO

TL U B

FE S ES

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

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

mental health

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

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

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

EMOTION NEEDS TO MATTER TO US

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

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

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

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

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

Youth Mental Health Crisis - G. Neufeld

Stress Response

Jack Hirose Seminars Fall, 2023

s Resilience Response lem b ro hp

IN EL

lt aFeelings he have been lthat

SF S E

tainhibited bounce

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

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

e or ec h T

M EE

N TIO

TL U B

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

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

The Continuum of ALARM Problems alarm is dysfunc;onal

alarm is perverted

ANXIETY problems (obsessions & compulsions)

AGITATION, ATTENTION, & DISCIPLINE problems

ADRENALIN SEEKING problems

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

driven by alarm that is not felt

devoid of feelings of alarm, fu$lity & vulnerability

alarm is displaced

including cuUng & burning ••• • •

• • HIGHLY ALARMED

•• •• •

The Continuum of Aggression Problems

EXISTENCE of attacking impulses

ERUPTIONS of attacking energy

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

VIOLATING aggression problems

devoid of feelings of alarm, fu$lity & vulnerability

• • HIGHLY FRUSTRATED • • • •

••

Youth Mental Health Crisis - G. Neufeld

Resilience Response

Stress Response

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

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

Jack Hirose Seminars Fall, 2023

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

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

ADULT

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

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

CHILD

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

ADULT

- wounding by others - not being held on to

we must HAVE their hearts before we can protect their hearts

- losses and lacks - peer or sibling rejection

CHILD

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

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

mental health

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

Attachment PEER ORIENTATION

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

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

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

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

Youth Mental Health Crisis - G. Neufeld

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

Jack Hirose Seminars Fall, 2023

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

children are not meant to take care of each other

The PEER-ORIENTED ...

society is not structured to facilitate peer togetherness

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

increasing tribalizaNon renders peer interacNon unsafe

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

IMPACT OF PEER ORIENTATION

CUT OFF from the care of parents and other caring adults

NOT SHIELDED by aMachments with caring adults

highly DEFENDED against the uncaring ways of peers

lacking SAFE SPACES for vulnerable feelings to return

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

INSIDIOUS IMPACT OF PEER ORIENTATION fragmented tribalization & polarization

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

insatiable attachment pursuit via digital devices and social media

increased alarm-based problems & vulnerability to wounding

elevated attachment frustration resulting in increased aggression including suicide

INSIDIOUS IMPACT OF PEER ORIENTATION fragmented tribalization & polarization

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

insatiable attachment pursuit via digital devices and social media

increased alarm-based problems & vulnerability to wounding

elevated attachment frustration resulting in increased aggression including suicide

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

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

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

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

Common manifestations of the DISPLACEMENT instinct ize

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

IMPACT OF AN ALPHA COMPLEX

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

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

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

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

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

How FEELINGS develop the Alpha Caring Response

Ca rin

“neurons that FIRE together WIRE together”

nsi eR spo

bi l i ty

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

the making of the bully response

highly moved to displace

Lacking feelings of caring & responsibility

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

- to assert dominance by exploiting vulnerability -

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

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

PEER ORIENTATION, the ALPHA COMPLEX and MENTAL HEALTH

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

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

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

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

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

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

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

the

ATTENTION

WINNING

the

APPROVAL

MEASURING UP

to be

VALUED

DEMANDING

to be

SPECIAL

IMPRESSING

to be

ESTEEMED

HELPING

to be

IMPORTANT

BEING NICE

to be

LIKED

BEING CHARMING

to be

LOVED

SEEKING STATUS

to be

RECOGNIZED

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

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

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

Scott Ms.Kerr

DEMANDING

to be

SPECIAL

IMPRESSING

to be

ESTEEMED by Not only is depersonalized

HELPING

to be

BEING NICE

to be

BEING CHARMING SEEKING STATUS

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

mental health

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

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

Right Relationships & Emotional Playgrounds

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

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

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

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

11/3/23

Working with the Highly Dysregulated Child Effective Interventions & Strategies with Children, Adolescents & Parents

Sit and breathe • Wait for any sense of discomfort (e.g. restlessness, an itch) • Note the desire to move and resist it • Notice thoughts that arise. These thoughts are just thoughts. So gently bring your attention back to your breath and bodily sensations. Note the changing position, shape and quality of the discomfort over time. Be interested in feeling it as precisely as you can. Notice how the shape and intensity changes with the cycle of the breath. • Is it stronger during the in breath or during the out breath?

Rudyard Kipling “Often and often afterwards, the beloved Aunt would ask me why I had never told anyone how I was being treated. Children tell little more than animals, for what comes to them they accept as eternally established.”

11/3/23

Today’s Objectives 1.

Understand the biosocial model of DBT in the context of a per vasive emotional dysregulation disorder in childhood development.

Understand the impact of trauma on the developing mind

Develop an understanding of the developing teenage brain.

Understand the impact of stress and trauma on development.

Identify techniques to harness and regulate the child and adolescent brain.

Understand how to apply DBT skills to most childhood disorders (e.g. Anxiety, Depression, PTSD, Eating Disorders, etc..)

Understand how to adapt DBT skills to meet the needs and challenges of children, adolescents, and family.

The Neurobiology of Trauma 5

Overview • Children can suffer from emotional vulnerabilities • Emotional vulnerabilities can come from many sources (e.g., attachment issues, loss, trauma), but is often assumed to be biological • Chronic and consistent invalidation exacerbates emotional vulnerabilities • An ongoing, reciprocal relationship exists between emotional vulnerabilities and environments

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Neighborhoods, churches, community centers, schools, service providers (e.g. health, legal, mental health), government

• Secure Base Parents, Grandparents, Extended relatives, mentors, teachers, leaders

• Safe Harbor Attunement,

• Proximity presence, Maintenance accountability, direction,

protection, correction, and connection.

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The Powerful Amygdala Key Features • Reactionary • Triggers Sensory System (Smell and Touch are the most direct pathways) • Controls autonomic responses

Stress & Cortisol

Our Survival Hormone

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• In utero assaults • Delivery difficulties • Health of both parents during conception • Mental Illness • Abandonment via adoption • Learning difficulties

• Divorce • Prolonged separation from parents and/or siblings • Frequent moves • School transitions • Bullying (Cyber, physical, etc.)

• Identity disturbances • Racial issues • Inside threats • Sexual assaults • Accidents (falls, vehicle, etc.)

Common Types of Invalidation ╺

╺ ╺ ╺ ╺ ╺

Abuse and neglect Being ignored Open rejection of thoughts, feelings, and behaviors Making “normal” responses “abnormal” Failing to communicate how experience “makes sense” Expecting behaviors that one cannot perform (e.g., due to developmental level, emotionality, or behavioral deficits

Excessive Cortisol Effects • Neurotoxicity to Hypothalamus • Neuron Death • Clogging of the corpus callosum connecting the left and right hemispheres • Suppression of the immune system

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Safe

Danger!

Life Threat

Acute Response to Threat Study Hyperaroused Continuum

Rest (Male Child)

Vigilance (crying)

Resistance (Freeze)

Defiance (posturing)

Aggression (hitting, spitting)

Dissociative Continuum

Rest (Female Child)

Avoidance (Crying)

Compliance (Freeze)

Dissociation (Numbing)

Fainting (checking out, minipsychosis)

Primary Brain Areas

Neocortex

Subcortex

Limbic

Midbrain

Brainstem

Cognition

Abstract

Concrete

Emotional

Reactive

Reflexive

Mental State

Calm

Arousal

Alarm

Fear

Terror

“In the brains of people who have been abused, the genes responsible for clearing cortisol were 40% less active” (Morse &Wiley, 2012) Acute Response to Threat; (Perry, Pollard, Blakely, Baker & Vigilante, 1995). Adapted from study results for teaching.

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What Happens During A Stress/Trauma Response?

Safety vs. Adaptation 20

HYPERAROUSAL

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

HYPOAROUSAL

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From Dysregulation to Self-Soothe The Purpose of Co-Regulation

Problematic Auto-Regulation is Learned

Cortisol

Oxytocin

SelfSoothe

Stress

Behavior

Window of Tolerance

Hyperarousal-Fight, Flight, Freeze,

Hypoarousal-Dissociation, Numbing, Depression

Sensorimotor Psychotherapy Institute® Sensorimotor Psychotherapy founder, “Pat Ogden

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Hormonal Counter to Cortisol=Oxytocin

Hormonal Counter to Cortisol=Oxytocin • Responsive • Activated through birth • Increases sense of safety and connection • Must act in order for it to be released • Can accumulate through repeated activities.

Now Doesn’t This Get Some Oxytocin Flowing?

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Treatment Targets to Increase Oxytocin Without Problem Behaviors

• Hugs • Sing in a choir • Give a back rub/foot rub • Hold a baby • Stroke a dog or cat • Perform a generous act • Pray

• Make positive eye contact • Breath work • Listen without judgment • Positive touch • Proximity • Laugh/Dance

DBT Theory: The Biosocial Model Understanding the impact of developmental and environmental trauma

Emotional Arousal

Coping-Avoidance Escape Behaviors Heightened Reactivity Innate Sensitivity Time

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The Biosocial Model ╺

Emotional vulnerabilities are characterized by: -

Emotional sensitivity

Emotional reactivity

Slow return to emotional baseline Over time emotions get sensitized, leading to a “kindling” effect This emotionality (and associated invalidation) is associated

╺

with many problems (disorders) Emotionality leads to escape and avoidance that leads to chronicity

Biosocial Theory Coherently Guides Treatment Targets and Strategies ╺

Validation is a primary intervention to: ╶

Reduce acute emotionality

╶

Provide gentle exposure to emotions

╶

Provide a corrective validating environment (and new learning)

╶

Create a bridge to learning self-validation

Open the client up to change interventions Emotion regulation is taught to:

╶ ╺

Understand how emotion happen

Reduce vulnerability to intense emotions

Increase opportunities for positive emotions

Assist in stepping out of ineffective mood-congruent behaviors

Biosocial Theory Coherently Guides Treatment Targets and Strategies ╺

Mindfulness (non-judgment and acceptance) is taught to: ╶

Reduce amplifying emotions

╶

Reduce escape and avoidance of emotions

╶

Create qualitatively different and effective experience of emotions Distress Tolerance is taught to:

╺ -

╺

Provide healthy ways of coping with emotions when

needed Use the theory to conceptualize the purpose of the interventions used

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Emotion

Function

Action Urge

Anger

Boundary, Identity, Injustice

Attack, Define a boundary

Protect from

Disgust

Reject, Separate

contamination/influence Obtain something not currently

Envy

Obsess, Aspire

possessed

Fear

Survival, Life Threat

Survival Defenses

To signal a threat to personal

Guilt

To make amends or apologize

morality

Happy

Connect with pleasure

Maintain

To signal a threat to an important

Jealousy

relationship

Love

Connect relationally

Connect, Sustain

To signal a loss (relationship or

Sadness

expectation) To signal a threat to social standards/expectations

Shame

Possess, Posture, Protect

Isolate, Withdraw Hide, Conform

Need

Age of Development

Healthy Development

Unhealthy Development

Key Emotions Impacted

Emotions

Threat Response

Fear, Happy, Anger Fear, Jealousy, Love

Survival

0-2

Security

2-3

Pleasure

0-3

Body-Self Development

Body Shame

Shame, Disgust, Envy, Love, Guilt

Affection

4-5

Capacity for love, sense of love and belonging, worthiness

Inhibition from autonomous connection

Love, Anger, Envy, Jealousy

Esteem

5-6

Recognition, Acknowledgement, Self-Acceptance

Lack of trust in self

Sadness, Shame, Guilt

Control

3-7

Choice

Compulsion, Impulsivity

Jealousy, Anger, Fear

Power

Intention

Invulnerability

Envy, Guilt, Fear

Self in Relationship Diffuse Boundaries

Rescuing the Dysregulated Child-Part 2 Parenting Styles, Interventions, and Strategies

11/3/23

Understanding Attachment Styles

Secure (60%)

Anxious/Preoccupied (20%)

Child Experiences and Behaviors

Feels “safe, soothed, seen, and secure” Child will be flexible, curious, and connected. Able to participate in relational ruptures and maintain a sense of connection even in disagreements

Caretaker Behaviors

Intermittently available or Creates a compassionate environment, rewarding and then will shift to able to regulate their own emotions and being unavailable and behaviors. Sees child as a separate misattuned. Might person. Moderately attuned (30%) to unintentionally look to their child child’s needs. Able to empathize and stay to meet their emotional needs. present with the child. Able to repair Turns to child to feel good about ruptures. self.

Adult Attachment Style (Working model of relationships based upon childhood)

Can trust others to be there for them as needed. Able to maintain their own unique identity while remaining connected to others. More satisfied in relationships. Marked with honesty, openness, and equal, and interdependent.

Feels “confused and frustrated.” Child might be clingy, desperate and anxious.

Has difficulty trusting others will there for them when needed. Maintains clingy and insecure behaviors. Seeks rescue versus establishing a real loving and trusting relationship. Frequently will test and sabotage relationships.

Avoidant/Dismissive (20%)

Disorganized (varies)

Feels that parent is an “emotional desert” Learns to get needs met by acting like they don't have needs. Becomes disconnected from emotions and presents with developmentally inappropriate selfreliance.

Feels frightened or terrified by their parent, experiencing fear without solution or resolution. Feels that their parents are unsafe despite the urge to seek security from them. Unpredictable and erratic behaviors marked with emotional turmoil.

Provides basic and instrumental needs for the child but will have trouble responding to the child on an emotional level.

Struggles with intimacy and has a hard time being vulnerable or showing any dependence on others. Often wards off partners attempts to be close, experiencing them as “needy.” May have difficulty remembering much from their childhood, and they may see early experience as having no impact on who they are as an adult. Tendency to lead more inward lives, turning off their emotions and can easily detach when threatened.

Engages in terrifying behaviors and unable to meet their child’s emotional, psychological, and relational needs. Not attuned to others

Learns that relationships are dangerous and will hurt you, but they desperately need others. They may be desperate or clingy when someone pulls away then aloof and withdrawn when someone comes toward them. Their behavior is often erratic and scary for their partners.

Understanding Parenting Styles

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Dem ocratic-Authoritative Parenting

Abusing-Authoritarian Parenting

High nurturance, expectations, and control Moderate communication

High expectations and control

Neglecting-Uninvolved Parenting Low nurturance, expectations, control and com m unication

Indulgent-Perm issive Parenting

Low nurturance and com m unication

High nurturance, m oderate com m unication, low expectations, and control

Parent Attachment Style & Adoption Parent Attachment Style

Autonomous/Free (Authoritative) Dismissing (Authoritarian/Uninvolved) Entangled (Permissive/Anxious) Unresolved (Authoritarian/Neglecting)

% of Low-Risk Adoption

% of Troubled Adoptions (e.g. trauma, abuse, illness)

Avoidant

20%

42%

Ambivalent

20%

42%

Childhood Attachment Type

American Population %

Secure

15%

Disorganized

1-2%

TCU Institute of Child Development . (Producer). (n.d.). Attachment Dance [DVD]. Available from TCU.

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Childhood Dilemmas Increasing Choices

Giving Perm ission

Connected

Supervising

Keeping World Sm all

Family Dialectical Dilemmas Excessive Leniency Fostering Dependence

Pathologizing Normal Behaviors

Limits Presence Forcing Autonomy

Normalizing Problem Behaviors

Authoritarian Control

What Does Earned Security Look Like?

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SECURE Safe

BASE

C onsistent

Safe Space

Care Providers

Lim its, R ules

PROXIMITY MAINTENANCE

Loving Well

SAFE HARBOR

School

Flexibility

Counselors

Attunem ent

Body

HOLISTIC INTERVENTIONS

Home

Mind

Rescuing the Dysregulated Child-Part 3 Childhood and Adolescent Disorders: Interventions and Strategies

Five Movements Mindfulness

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Key Childhood to Adolescent Disorders

Anxiety • Anxiety is an adaptive response to threat (and the traumatized client expects threat) • Validate the feelings and sensations as real and experientially work with the somatic experience that the feelings are intolerable • Balance mindful acceptance of anxiety with relaxation and grounding skills(e.g., breathing, muscle relaxation, positive self-talk, self-soothing skills) • Realign therapeutic environment that threatens to dysregulate your client.

Attention-Deficit/Hyperactivity Disorder

• Assess for history of Traumatic Brain Injury as recent studies indicate a correlation between trauma and ADHD (McIntosh, 2015) • Hypervigilance resembles hyperactivity and might be easily misinterpreted (Littman, 2009) • Focus on nutritional management strategies-hydration, omega-3 fatty acids, targeted amino acid therapy (TAAT) (Purvis et al, 2007) • Assess for compromised parenting as impulsivity and compromised executive functioning inhibits proximity maintenance and structuring the environment appropriately (e.g. safe harbor) • Target in-session activities that activate the observing mind and a restful mind state

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Oppositional Defiant Conduct Disorder • Multifamily attachment interviews • Bring a family therapist on the team and open up multifamily trauma skills training to all supporting family members • If there is an extensive history of trauma, practice strategies of avoiding the word “no” as it sends the child out of his or her window. • Keep child’s world small and predictable with immediate consequences

Behavioral Principles Positive Reinforcement: behavior is followed by a reward, increasing the b’s frequency Negative Reinforcement (think avoidance learning): behavior is followed by removal of something aversive, increasing the b’s frequency Positive Punishment: behavior is followed by something aversive, decreasing the b’s frequency Negative Punishment (think response cost): behavior is followed by removal of something, decreasing the b’s frequency Extinction: removal of any consequence for a behavior, leading to a decline in the b

• •

Behavioral Principles

•

Shaping: reinforcing approximations to a desired behavior Avoidance Learning: behavior results in the cessation of an aversive stimulus (falls under negative reinforcement) Non-contingent Reinforcement: providing reinforcement regardless of behavior you want to decrease (but in absence of that behavior). The b then decreases as it is no longer necessary to receive the reinforcement Generalization: performing desired behavior outside of treatment setting

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Best Behavioral Methods to Create Change Make Reinforce

Make a high probability behavior contingent on a low probability behavior (i.e., Premack Principle)

Reinforce anything and everything that is not a problem behavior (clients emit positive behaviors nearly continuously)

Train

Train a new behavior (skill) to reinforce

Cue

Put a problem behavior on “cue” (i.e., bring it under stimulus control)

Understand

Understand the motivation for the behavior and use it to leverage change

Attachment Disorders • Stability first! Child must have skills to tolerate distress and remain in the window (e.g., work on grounding skills, distress tolerance, and emotion regulation) • Incorporate emotion regulation strategies that hyper or hypoarousal patterns(e.g. aggressive connection or dissociated drifting to strangers) • Develop healthy connective strategies through somatic exercises

• Teach boundaries and learning how to sense the body for child and parent

PTSD and Trauma • Utilize ”parts” work in sessions to identify dissociated emotions, thoughts and memories (Fisher, 2017) • Embody and model mindfulness skills • Utilize somatic interventions should client leave the window • Incorporate Connected Child (Purvis, et.al, 2007) work into work regarding discipline strategies (e.g. Trust Based Relational Interventions (TBRI)

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Trauma Timeline (Keck)

Depression

§ Depression in trauma happens when survival strategies are frustrated, making hope difficult and leading to greater passivity.

§ Validate the mood, especially given lack of positive experiences (reduces secondary guilt and shame). § Focus on activating responses in the body.

§ Build mindfulness practice.

§ Build in self-care and emotion naming and resourcing skills

SOUL COLLAGE CARD ACTIVITY

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Key Interventions and Strategies Building your relational toolkit

What to Look For SelfInvalidation

• Self-hate/criticism • People-pleasing • Perfectionism

Emotional Vulnerability

• Anger, Bitterness Towards Others • Fragility, Vulnerability

Inhibited Experiencing

• Active avoidance • Passive avoidance, dissociation

How to Help Self-Invalidation • Modeling failure • Communicating validation

Emotional Vulnerability

Inhibited Experiencing

• Model self-care • Create a safe home environment

• Model Emotions • Display authentic reactions without exaggeration

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What to Look For Unrelenting Crises Active Passivity Apparent Competence

• Uncontrollable Events • Crisis-Generating Behavior

• Willfulness, Demandingness • Helplessness

• Disconnect between verbal and non-verbal behavior • Contextual Competence (mood/situational)

How to Help Unrelenting Crises

Active Passivity

• Control the Controllable in the Home • Practice/Model Delayed Gratification

• Cheerlead • Encourage problemsolving • Set Personal Limits

Apparent Competence • Highlight effective behaviors observed • Lose the assumption of how the loved one “should” behave in all contexts based upon one.

Building the Resource Toolkit

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Resource Domains (Ogden & Fisher, 2015) Somatic

Psychological

Spiritual

Relational

Artistic/Creative

Nature

Emotional

Intellectual

Somatic ▫

Internal

▫

External

Relational Internal ▫ Sense of “love and belonging” (Brown) ▫ Ability to reach out and experience connection ▫ Establishing healthy boundaries

External ▫ Friends ▫ Family ▫ Mentors ▫ Spouses/Partners ▫ Pets

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Emotional Internal ▫ Access to the full range of emotions, expressions, and sensations ▫ Ability to modulate high to low arousal ▫ Ability to tolerate intensity of emotionality

External ▫ Relationships to give and receive emotional support ▫ “Sister or Brother”-circles ▫ Activities that elicit high and low emotional arousal

Intellectual Internal ▫ Creative thinking ▫ Dreaming ▫ Imagination ▫ Learning

External ▫ School ▫ Classes ▫ Study groups ▫ Puzzles ▫ Books

Artistic/Creative Internal ▫ Capacity to access creative processes ▫ Imagination ▫ Vision

External ▫ Art materials ▫ Creative writing groups ▫ Cooking classes ▫ Music (e.g. cds/access to music) ▫ Museums

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Material Internal ▫ Ability to rest ▫ To enjoy the comforts of life ▫ Experiencing pleasure

External ▫ Home ▫ Comfortable bedding ▫ Life hacks

Psychological Internal ▫ Strong sense of self ▫ Self-awareness ▫ Esteem ▫ Compassion ▫ Nonjudgmental ▫ Resiliency

External ▫ Access to a therapist ▫ Workbooks ▫ Manuals ▫ Support groups

Spiritual Internal ▫ Ability to develop connection with a Someone or Something greater than one’s self ▫ Capacity to connect with one’s own spiritual essence

External ▫ Meditation ▫ Contemplative Prayer ▫ Shabbat ▫ Spiritual mentors

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Nature Internal ▫ Utilizing your senses to take in the world around you ▫ Sensory bathing

External ▫ Gardens ▫ Parks ▫ Hiking ▫ Plants in the home

Validation: The Keys to the Kingdom • Validation is the non-judgmental acknowledgement of the child’s experience • Validation creates the conditions of acceptance that usually precede change • As a rule, start with validating the child, and return to validation when the child is “stuck” (remembering that rules have exceptions)

Balance of Validation and Change • Validation opens kids to change: - Lets kidsknow you understand the nature of their issues and pain - Exposure to painful emotions create a qualitative difference in relating to emotions (decreasing ineffective escape and avoidance behaviors) - Exposure to painful emotions can create motivation to invest in change

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Slowing Down and Pacing • Validation is NOT a means to an end • Validation requires time to be processed • Moving too quickly sends unintended messages about emotions and distress • Children will typically let you know if too much time is spent on validation

Levels of Validation (Linehan, 1997) • Being acutely attentive (V1) • Reflecting verbal communication (V2) • Describing non-verbal communication (V3) • Expressing how experience makes sense given history or biology (V4) • Expressing how experience makes sense in the present moment and context (V5) • Being in genuine, human contact (V6)

Validation as an Exposure Technique • Regulates emotions by decreasing their intensity • Provides gentle, informal exposure to emotions with a sense of self-efficacy • Allows for a more complete expression of emotions, cueing a fuller adaptive response

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“

The curious paradox is that when I accept myself just as I am, then I can change. Carl Rogers

Rescuing the Dysregulated Child-Summary Pulling it all together

In Summary • Change does not happen overnight. • Assume that you and your children are doing the best you can. • Validation are the keys to the kingdom. • Validation precedes change and challenge. • Attachment endures throughout the lifespan. No attachment is fixed. • The areas of the brain that are compromised in early attachment trauma are the most neuroplastic. • Commit to keeping your child’s brain at rest.

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Thank-You • Eboni Webb PsyD, HSP ewebb@webbjamconsulting.com 615-589-1018

The Village of Kairos 1451 Elm Hill Pike, Suite 250 Nashville, TN 37210 367 Riverside Drive, Suite 104 Franklin, TN 37064

11/23/23

Using IFS-Informed EMDR for Complex Trauma

Daphne Fatter, Ph.D. (She/Her) Licensed Psychologist IFS Certified & IFS Consultant EMDRIA Certified & EMDRIA Consultant in Training (CIT)

Scope of Practice Materials that are included in this course may include interventions and modalities that are beyond the authorized scope of practice for your profession. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your profession’s standards. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Learning Objectives

Identify

•Identify overlapping theoretical underpinnings of both EMDR and IFS models.

Describe

• Describe an example of how to use an IFS-Informed intervention.

Recognize

•Recognize when STARR can be used in EMDR treatment.

Distinguish

•Distinguish which IFS-informed intervention could be helpful when Phase 4 processing is blocked.

Apply

•Apply at least 2 IFS-informed interventions to use during EMDR's 8 Phase model

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Eye Movement Desensitization & Reprocessing (EMDR) • Francine Shapiro, Ph.D. developed in 1989. • Goal: • Process trauma memories to “adaptive resolution” • Unmetabolized distressing memories are reason for client’s cognitive/emotional/somatic reactions • Eye movements (and/or other bilateral stimulation) helps clients process memories and make adaptive associations between memory networks. (Korn, 2009; Shapiro,2018) 4

Current Research ØRecent systematic review, EMDR is effective for PTSD treatment (see Maxfield, 2019 & Novo Navarro et. Al., 2018 for review). ØResearch supports its effectiveness for telehealth with CPTSD (Korn, 2009; Bongaerts et al., 2021). ØOver 80 percent of the clients in study no longer met the diagnostic criteria of PTSD and Complex PTSD after EMDR (Bongaerts et al 2022). ØAs shown in PET scans, clients had a clear clinical improvement in PTSD symptoms associated with metabolic and electrophysiological changes in limbic and associative cortex (Pagani et al., 2018). ØEffective treatment approach across cultures, and cross-culturally (Wilson et al., 2018). Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Internal Family Systems

• Richard Schwartz, Ph.D. developed it 40 years ago. • Goal: • Reorganize internal system so Self is leader. • Help Client live from Self, rather than living from parts. • Liberate parts from the extreme roles they were forced into so they can share their natural valuable gifts. • Balance/harmony within a flexible internal system. (Anderson et al., 2017; Anderson, 2021; Schwartz, 1995; Schwartz & Sweezy, 2020; Schwartz, 2021) Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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1.The psyche is innately divided into sub-personalities, called parts. Internal Family Systems: 2. A Systems approach can be applied in individual therapy Foundational Principles to an individual’s system. 3.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.

• (Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021) 7

What is Self? 8 C’s 5 P’s Curiosity Presence Calm Perspective Compassion Persistence Courage Playfulness Creativity Patience Connectedness Clarity Confidence (Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021) Copyright © 2023 Daphne Fatter, Ph.D.

Types of Protective Parts

(Anderson et al., 2017; Anderson, 2021; Schwartz, 1995; Schwartz & Sweezy, 2020; Schwartz, 2021)

Managers

Proactive helper parts that pre-emptively prevent exiles from getting triggered.

Firefighters

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Exiles

(Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz, Schwartz, & Galperin, 2009; Schwartz,1995; Schwartz, 2021)

• Parts that experienced attachment/relational injuries and traumas. • Hold the emotional and physical pain, beliefs, and body sensations 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.

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 (e.g. 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) Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Shared Principles Both Models Share Trust in the Client’s Capacity to Heal (Fatter, 2023): • EMDR: The Adaptive Information-Processing system (AIP) naturally exists in all of us (Shapiro, 2018). • Theoretical underpinning of EMDR (Hill, 2019; Shapiro, 2018). • IFS: Everyone has Self which is undamaged by trauma (Schwartz, 2021). • Multiplicity of the psyche; Parts can shift roles. • Intrapersonally IFS repairs between Self and Part help parts unburden. Both Models are Trauma-Informed: • EMDR -> ‘Every Memory Deserves Respect’ (Baldwin & Korn, 2021). • IFS -> All parts are welcome. Non-pathological approach (Schwartz, 2021). • Both Honor the nervous system of the client and somatic memory. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

11/23/23

Shared Principles Both Models Elicit the Ability to Reorganize the Client’s System (Fatter, 2023): • EMDR (Shapiro, 2018): • Through process of having new information connected with inadequately encoded traumatic memory network. • Desensitizing traumatic memory, shifting cognition, affect, and body sessions associated with targeted traumatic memory. • IFS (Schwartz & Sweezy, 2020): • Goal of IFS is to liberate parts so their natural roles/states can be restored. This happens relationally. • Re-organization happens in the client’s system through internal relational repair à Restore trust in Self and Self-leadership. • Both EMDR & IFS Elicit Memory Reconsolidation (Ecker, Ticic, & Hulley, 2012; Fatter, 2023). Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Memory Reconsolidation (Ecker et al., 2021)

EMDR

IFS

(Ecker et al., 2021)

(Anderson, 2021) Self to Part Relationship

Dual Attention

(Visual Adapted from Anderson, 2021)

Accessing Sequence: Phase 3 • Moves from Implicit to Explicit

Self Befriending Exile

Transformational Sequence: • Re-activation and Mismatch

Phase 4

Witnessing and Do-Over

“Erasure” Sequence: • New Experiential Learning; • Occurs within 5-hour window

Phase 4, Phase 5, & Phase 6

Retrieval, Unburdening, Invitation and Integration

Differing Approaches (Fatter, 2023)

• Models differ in their approach used for emotion regulation & assessing client ‘readiness’: • EMDR: • Phase 2: Identifying a client’s window of tolerance. • Resource Development for affect tolerance, ‘Installing resources’ & client expected to use these coping skills, grounding and relaxation resources throughout treatment. • IFS: • Befriending protectors & contracting with exiles not to overwhelm system. • Occurs when trust in Self is restored. • Models differ in how each model accesses traumatic memory: • EMDR: Organizes treatment plans and potential targets around the Negative Cognition, emotions and body sensations. • IFS: Client’s Self befriends protectors first, gets permission to work with exiles. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

11/23/23

Why Integrate? (See Fatter, 2023)

´Research recommends a multi-intervention and multi-method approach for complex trauma (Cloitre, 2020; Cloitre et al., 2020; Cloitre, 2021). ´Benefits: Integrating = Enhances individualized treatment plan (Fatter, 2023): Ćonsent-based with protective parts; Decreases risk of decompensation. Áttunes to client’s system where they are; contributes to strong working alliance. Áttachment-oriented & relational => Reparative intrapersonally =>attends to conscious (via IFS) and non-conscious (via EMDR) re-organization. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Simple vs complex trauma First proposed by Herman (1992a) “Complex PTSD: A syndrome in survivors of prolonged and repeated trauma” as Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Complex trauma = CPTSD (Complex PTSD) Ideally, personalized treatment plan for both PTSD & CPTSD (Cloitre, 2021) Research has shown that PTSD and CPTSD have distinctive key features: Ø Across at least 15 countries; Over 40 studies (Cloitre et al., 2020). Ø CPTSD have “disturbances in self-organization that are pervasive and occur across various contexts: emotion regulation difficulties (for example problems calming down), negative self-concept (for example beliefs about self as worthless or a failure) and relationship difficulties (for example avoidance of relationships)” (Cloitre, 2020, p.130).

Why Integrate IFS-Informed interventions into EMDR? (Fatter, 2023)

EMDR: • EMDR needs to be adapted and tailored to address the specific needs and challenges associated with complex trauma treatment in both adults and children (Shapiro, 2018). • Clients with complex trauma may also experience greater difficulty engaging in the stand-alone standard protocol for EMDR due to: • The nature of their trauma history, complex symptomology and likely comorbidity with other psychiatric disorders. • Standard EMDR protocol may inadvertently bypass protectors who client nor clinician were aware of. • Integrating EMDR & IFS provides a flexible and adaptable consent-based & attachment-oriented treatment plan. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

11/23/23

Why Integrate? (Fatter, 2023)

• Once system has given consent -> more expedient: • EMDR can attend to multiple exiles; parts on entire memory network. • If difficulty staying in Self when witnessing exile (e.g. in Big T trauma). • Difficulty unblending from somatic parts. • Strengths of EMDR – rapid trauma processing: • In review of RTC of EMDR, 7 of 10 studies reported EMDR therapy to be more effective and/or more rapid than trauma-focused cognitive behavioral therapy (Shapiro, 2014). 19

Determining Factors to Integrate (Fatter, 2023)

• Needs more stabilization before EMDR (Self-to-part via IFS) to do during Phase 2. • Has complex symptomology: Complex PTSD or Complex Trauma History • Has Current Stressors & Invasive PTSD symptoms currently interfering with functioning: • Practical Indicator in traditional EMDR: clinician difficulty being clear on which trauma to start with due to current stressors and complex trauma history. • Go with current stressor first or most invasive stressor. • Client reports can’t remember what you did last session (Amnesic Parts) or reports decompensation in between sessions (i.e. “backlash”). • Client has difficulty with state change making clinician hesitant; difficulty in determining client’s readiness/capacity of their window of tolerance. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Art Form of Integration: Meeting Clients Systems Where They Are (Fatter, 2023)

• EMDR -> Speeds Up Witnessing which is helpful when: • many traumatic memories over course of one’s life. • many parts on a memory network, including many exiles sharing the same burden. • multiple parts activated at same time.

• IFS-> Slows down –

• Helps Parts repair with Self. • Integration via Self to Part at the end of any Phase 4 EMDR session and after a target clears. • Helps if protector backlash after any Phase 4 session (e.g. SI, Plan, Intent, Firefighters). Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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Limitations & Risks to Integration (Fatter, 2023)

Guidelines of Evidence-Based Practice in Psychology (EBPP) (APA, 2021): 1. Best Available Research 2. Clinical Expertise 3. Patient Characteristics, Culture & Preferences

• No research on integrating these two models. • Case studies only (Krauze & Gomez, 2013; O'Shea Brown, 2020; Twornbly & Schwartz, 2008).

• Need for treatment fidelity (Finley, Mader, et al., 2018)

• Ethically, therapists would need some competency in both models.

IFS-Informed Interventions for EMDR (Fatter, 2023)

• Lots of Choices on how much to integrate EMDR. • Principle-Based: Any IFS-Informed interventions is relational – is intrapersonally connective & reparative between client’s Self and target part. • Once you start EMDR protocol, return to EMDR protocol after any IFS Intervention. • If you pick only one IFS informed intervention to integrate: • Ask “Check inside -- any there any parts that have fears or concerns about targeting the specific trauma in EMDR.”

“EMDR Eight-Phase Protocol

IFS Steps”

Phase 1: History taking, treatment planning, &

Assessing external constraints, track sequences, parts

consent for treatment plan

mapping, contracting about treatment plan and contract to shift to experiential IFS of the 6 Fs.

Phase 2: Preparation & resource development

Using the 6 Fs to Befriend managers and firefighters and obtain permission from protective system. Relational

Fatter, 2023, p. 83; Used with Permission

repair between Self and protective parts. Befriending Exile. Phase 3: Assessment

Accessing and activation of Exile

Phase 4: Desensitization

Witnessing the target exile, do-over, retrieval, unburdening

Phase 5: Installation

Invitation of positive qualities

Phase 6: Body scan, future template

Assessing for further unburdening needed to release bodyrelated and/or physiological burdens carried by target exile(s).

Phase 7: Closure

Integration. Appreciation to protectors, invitation to witness unburdened exile, invitation for protector unburdening.

Phase 8: Reevaluation

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Phase 1 with IFS-Informed Approach (Fatter, 2023)

EMDR (Shapiro, 2018) • History taking & treatment planning • Getting informed consent. • Assessing client readiness, capacity and timing in client’s life. • Classic EMDR treatment planning: • The most 10 disturbing memories from childhood. • Gathering data on Adverse Life Experiences.

IFS (Fatter, 2023) • Client’s clinical presentation = well-intentioned burdened parts trying to help. • Assessing for External Constraints. • “Are their any parts that have fears & concerns about the treatment plan/goals, or doing EMDR”? Track sequences, parts mapping. • Contract to shift to experiential IFS of the 6 Fs for Phase 2.

Assessing a Client’s Window of Tolerance (Fatter, 2023)

Examples of integrating an IFS-informed approach to Phase 1: • How does client respond when a part is activated: • “How much Self-energy can a client access when activated by a part?” • “How does the client respond if and when there is extreme activated in between sessions?” • Unblending: • “How easily can the client unblend from an activated part?” • “If the client has difficulty unblending, or accessing Self, can the client receive the support of Self-energy from the therapist when needed?” • Assess Self-to-Part relationship: • Is there ‘enough’ Self-energy for a client to be in Self and access a part at the same time? 26

Option to do Parts Mapping (Fatter, 2023)

Protector

Post-Partum Anxiety

Protector

Client’s Self

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Phase 2 Why integrate IFS here (Fatter, 2023)? • Standard Resource Development may bypass client’s protective systems:

EMDR (Shapiro, 2018): • Preparation & Resource Development. • Safe/Calm Place Visualization, with cue word; State Change.

• Relaxation can be a trauma trigger for some complex clients. • May feel helpful to some parts – but not all parts; May disorient system. • May disarm protective system ->which can elicit backlash in client’s system.

• Befriending protectors & getting permission to work with exile. • This is experiential IFS (not just talking about parts), but client being with their parts. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Used with Permission

Using 6F’s to Befriend Managers & Firefighters in Client’s system (Anderson et al., 2017 Anderson, 2021; Schwartz, 1995; Schwartz & Sweezy, 2020; Schwartz, 2021)

1. Find: "Where do you notice this part in or around your body?" 2. Focus: "Give your attention to this part." 3. Flesh it out: "How are you experiencing it right now?" (image, felt sense?) 4. "How do you Feel Towards this part?" (Checking for Self Energy) 5. Fears: "What are this part's Fears and Concerns?" 6. BeFriend part: "How is it trying to help you?“

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• Getting to know client’s protective system • Addressing fears/concerns experientially • Identifying ‘Blocking Beliefs’ = well intentioned parts protecting client’s system. • Getting internal consent to access exile • Widening window of tolerance (through Self to part relationship).

Goals of Befriending Protectors

Protector Consent Helps Decrease Risk of Backlash

• Helps set EMDR for success, particularly in complex systems. • Minimizes blocking, or interruption in Phase 4. • Decrease adverse reactions in between sessions. • (Fatter, 2023; O’Shea Brown, 2020; Twombly & Schwartz, 2008)

Using STARRTM: Self-Tapping for Attachment Readiness and Repair (Fatter, 2023)

Use When a Client is “blended” (merged with a part): • What if client can’t access Self Energy? • Protectors have difficulty taking in client’s Self’s presence. • Exile parts are taking the session over and client is overwhelmed?

• STARRTM is a multi-sensory option for the target part to initially receive Self-energy from the client. • Slow self-tapping -> as a means for the client’s Self to communicate to parts. • Initiates an attachment repair process between Self and the IFS target part. • “Call and response” communication.

3333

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STARRTM: Self-Tapping for Attachment Readiness and Repair (Fatter, 2023) From EMDR Lens • Physiological Benefits of slow BLS. • BLS when paired with positive imagery can increase relaxation & positive affect (Amano, & Toichi, 2016) and naturally elicits relaxation (Girianto et al., 2021).

From IFS Lens • Intentionally fostering relational connection between Self and target part. • Used with parts that have a difficult time taking in Self Energy.

How to Practice STARRTM (Fatter, 2023)

• Mechanics are the same as ‘Butterfly Hug’ (Artigas et al., 2000; Jarero & Artigas, 2022; Artigas & Jarero, 2010); • Self-tapping is traditionally used in EMDR’s Phase 2 to strength resources (e.g. Parnell, 2008) and during trauma processing in Phase 4 (Jarero & Artigas, 2022; Artigas & Jarero, 2010). • STARRTM intentionally uses slow self-tapping for relational connection within the internal system of the client. • Client uses STARRTM for 20 seconds or less during which both the client and therapist are quiet • Client pauses the self-tapping to see how the target part received and is responding to receiving the slow self-tapping as an initial form of communication from Self. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Directions for STARRTM •

“Let’s try using slow tapping to send the part the message that you are right here

with it, feel compassion towards it, and want to get to know it. Just invite the part to take in the rhythm, the sound, and the vibration of the tapping.” •

(The client uses STARR for 20 seconds or less)

•

(Fatter, 2023, p.87)

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Phase 2 • Alternatives to Traditional Container (Fatter, 2023): • Container originated from Shapiro, 2005; Kluft, 1988. • We don’t put parts in containers. • Can ask part then if it wants to contain anything, as they are in connection with Self. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

Phase 2: “No parts left behind”

Reframing Calm/Safe place as place for target part to be retrieved to & for relational repair with Self (Fatter, 2023). • Exile choses where to be to have connection with Self. • E.g. “As we prepare to end the session, ask the part in this scene, would they like to leave the scene and be with you in a place that feels calm and safe?” • Retrieval to leave time period they are in; to be a place of their choice where they can have access to Self • Usually in present day so part can be updated as to client’s current Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without life & capacity. 38 Permission

IFS-Informed Phase 3 (Fatter, 2023)

• EMDR (Shapiro, 2018): • Assessment

• Accessing and activating memory network with exile on it. • Therapists have flexibility with how much to integrate IFS into EMDR Phases. • No matter how you access traumatic memory, only proceed with permission from protectors. • It is normal for there to be many protectors in complex trauma (Twombly, 2022). • Can invite protectors to watch processing in Phase 4 (Fatter, 2023; O’Shea Brown, 2020; Twombly & Schwartz, 2008).

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Three Common Scenarios in Accessing Target for Phase 3

(Fatter, 2023)

1. Organic Emergence from Client’s System: • Befriending Protectors -> Protectors organically reveal target exile; Get permission from exile. • Exile becomes target exile for Phase 3 & Phase 4 trauma processing. 2. Client says: “I want to work on……”. • Get consent of protectors: “Are there any fears or concerns any parts of you have about working on….”. Befriend protectors as needed using the 6 F’s. • After receiving consent from any protectors, ask “Where is this part(s) right now in and around your body carrying memories of…..” or move into traditional Phase 3. 3. Multiple Parts are activated/blended with client: • Get consent of protectors: “Are there any fears or concerns any parts of you have about working on….”. Befriend protectors as needed using the 6 F’s. • After receiving consent from any protectors, welcome all the parts related to target – the brain will take you where it needs to go in EMDR for healing; Move into Phase 3. e.g. grief/loss. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission 40

Case Example: Befriending in IFS, then Switching to EMDR.

Case Example • Video Clip: Asking for Permission and Moving to Phase 3 with connection between Exile and Self. • What you will watch: • Before Phase 4:

• Using the 6 Fs with angry part, getting consent to do EMDR. • Continuing to befriend exile (anxious part in fetal position) and get permission to do EMDR.

• After Phase 4:

• Returning to Self to connect with target exile, making sure exile is retrieved, client sets intention to check in on exile. • Integration: Asking protector part to see exile now – anything the protector needs from Self. Copyright © 2023 Daphne Fatter, Ph.D.

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IFS-Informed Phase 3 (Fatter, 2023)

• Target Traumatic Image (e.g. first, worst or most recent memory) from target exile(s). • Negative Cognition = the Target Exile’s Beliefs/Burdens • Positive Cognition & VOC = Inviting in flexibility; The therapist can hold curiosity here. • In applying an IFS lens into EMDR’s Phase 3, the positive cognition (PC) and validity of cognition (VOC) may be coming from protector or the target exile. • Exile’s Feelings. • SUDS (i.e. level of disturbance on scale of 0-10) according to exile. • Location in Exile’s body.

In this video:

Setting up Phase 3 when client is Blended & Ending Incomplete Session

Client’s Self Energy Target Phase for Phase 4: Exhausted & Anxious: Pulled in all directions; Hasn’t had a voice.

Protector: “It could be worse” Don’t want to be ungrateful.

Before Phase 4: - You will see how to navigate a blended system starting with IFS, having one protector watch on sidelines. - Getting consent of client’s system. Closure of incomplete session: - SUDS decreased to 2 by end, returning to Self to part at end, inviting target part to use container and go to calm place with client.

Attuning for Cultural Trauma & Legacy Burdens From EMDR Lens (Robinson, 2023) • Client having somatic reactions, images, beliefs that are not from their lived experience or highly charged to ancestral stressor. • Can target specific transgenerational memories or disturbances from collective memory; maladaptive beliefs. • Embrace a legacy-based core positive cognition related to identity/culture, belonging. • Ancestral: Proposed 4th prong (Dr. Karen Alter-Reid, 2023)

From IFS Lens (Sinko, 2017) • Therapist can ask: “How much of this belongs to you?” “ “How much of this has been passed down?” • If client says: • “Its always been there” • “This is so much bigger than me” • “My parent..my grandparent,....had this too”; “I don’t know, but its always been there.”

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Phase 3 Examples of Neg cog = Exiles’ Burdens

• I am less than. • I don’t belong. • I’m invisible/I don’t matter. • I can’t connect • ** these may open up memory network related to oppressionbased trauma or intergenerational material, even if that is not the targeted trauma in EMDR (Archer, 2021; Ashley & Libscomb, 2023).

If processing cultural or oppressionbased trauma:

• EMDR: “As you think of yourself as a _____(cultural identity/intersectional identity), What words go best with that picture that express your negative belief about yourself now?” (Nickerson, 2023b, p 99) • IFS: Ask Exiles that client has befriended.

IFS-Informed Phase 4 (Fatter, 2023)

EMDR (Shapiro, 2018): Desensitization • Decreased emotional and sensorimotor reactivity to a specific traumatic memory. • Client experiences BLS sets while focusing on a specific traumatic memory targeted during Phase 3.

IFS: Healing Steps (Befriending Occurred during Phase 3) • Witnessing the target exile(s) • Do-Over • Natural updating exile(s) • Unburdening • Retrieval at end of session • Multiple parts involved:

• A different part may speak/be witnessed during a given set.

Phase 4 & Targeted Memory Network • Memory Network in EMDR = system of parts (both protectors & exiles) via IFS lens. • Each set in Phase 4: likely a different part may be answering, blended with the client, or may hear more Self energy in answers. • Over course of Phase 4 processing More Self Energy. • (Fatter, 2023) Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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IFS-Informed Interventions When Stuck (Fatter, 2023)

• Restore Self-to-part connection through Befriending, make sure exile in present scene feels seen by Self, then resume bi-lateral stimulation. • Example: “How do you feel towards part in scene – let them know that. How are they responding?” Relief – “Go with that.” • Case Example: Grief of father • Not changing in specific scene/heaviness in chest. • Befriended sad part in scene in hospital room - acknowledging how alone she felt – “go with that” • Befriending sad part: “I'm telling her it’s okay to feel sad and telling her that she is not alone” – “go with that” Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

During Phase 4: use “Simplified IFS” for Restoring Self to Part Connection (Fatter, 2023) Move Toward: Notice, Know, and Need (Riemersma, 2023): • “What do I notice right now in my body, mind or emotions” (p. 28) • “What do you want me to know” (p.34) • “What do you need right now to feel more comforted” (p.35)

Initial Befriending (Before 6 F’s) (Floyd, 2023, p. 91) • “What does the part want you to know about itself?” • “How do you feel toward the part?” • “What might the part need from you?”

Blocking Beliefs (Fatter, 2023)

EMDR (Shapiro, 2018): • Firmly held belief interrupting Phase 4. • Examples: • Fear of being overwhelmed. • Fear of losing good memories. • Success, failure, disloyalty to parents, loss of identity.

IFS: • Pause BLS, ask the 6 F’s: “What part is blocking and what are their fears/concerns? What is it afraid would happen if they did not do their job?” • Facilitate Self to part connection and ask protector to watch exile receive healing from sidelines. • May be Legacy Burden.

51 51

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Case Examples that Warranted IFS Befriending 1. Multiple loss that have not fully been processed:

• “If I let myself feel the grief, I will feel an ocean of endless sorrow and it will never stop.”

2. Cultural Belief regarding how to respond when opportunity comes: “If I say no to opportunity, it will never come back”; • Connected to immigration trauma; • Migration Trauma: Before, during, and after migration (Penailillo, 2023). • “Legacy Material” (term from Dr Forrest Merrill)

Case Examples of Honoring Multiplicity 1. Phase 4 processing stuck: I need to respect and be grateful for my parents and my mother is abusive. Example of interweave: “A part of you is grateful for mother helping you when your daughter was born, and a part of your mother is mean.” (this is client’s language) 2. When polarizations/conflicting feelings/views: Adapted with IFS‘Two handed interweave’ (Shapiro, 2005) ; Example of interweave: “Invite one part in one hand, and another part in another hand and Notice that.”

IFS-Informed Interventions When Stuck (Fatter, 2023)

• Do-Over: Having Self of client be with the exile in the scene they are in.

• “Would this part like you to be with them in the scene?” “Be with the part in whatever way they needed and didn’t get at the time.” • Reparative between exile and Self: emotionally corrective experience.

• Updating: Have Self update exile with information from present day that they don’t know. • E.g. “How do you feel towards the part – let them know that” • “What information does this part need updated on? Give them an update.” • e.g. perpetrator is dead; you are all grown up; present day image of sibling/parent that exile feels loyal to. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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Example: Do-Over

Do Over: Client went to be with exiled part right before delivery, explained her medical risk, and risk of son going to NICU.

Client’s Self

Game Time! Let’s practice the options for Phase 4 IFS-informed interventions: The therapist says: “How do you feel towards part in scene –(client responds with qualities of Self). “Let this part know that. How is the part responding?”

What IFS intervention is the therapist using? Befriending: Fostering Self-to-part connection

Retrieval

Do-Over

Game Time! The therapist invites the client to ask the exile if they would like the client’s Self to be with them in the scene they are in – the Client’s Self is with the exile being with them in whatever emotionally corrective way they needed at the time.

What IFS intervention is the therapist using?

Unburdening

Do Over 57

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Game Time! The therapist invites the client to update the target part with information from present day that the part may not know.

What IFS intervention is the therapist using?

Updating

Retrieval

Do Over 58

Game Time!

You (the therapist) started an IFS-informed intervention due to a client’s Phase 4 processing getting stuck, once you have Self to Part connection, do you return back to Phase 4 processing via EMDR?

Yes

Checking SUDS (Fatter, 2023)

• If not a 0, but a low SUDS – “ask the part that feels the image is a 2, to share what is making it a 2” – “go with that” • When 2 is ecologically valid, can befriend parts that are holding it at a 2. • Case Example: Latino Male targeted multiple racial traumas. • Befriended protector part that needed to stay vigilant to potential danger. • Self-to- part relationship.

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IFS-Informed Phase 5 (Fatter, 2023)

EMDR (Shapiro, 2018):

IFS:

• Installation of Positive Cognition

• Asking parts what positive qualities they need now or in the future? • “What positive qualities would the target part or group of parts that experienced healing like to take in?” 61

IFS-Informed Phase 6 (Fatter, 2023)

EMDR (Shapiro, 2018):

Body Scan

IFS: • Attends to somatic/physiologically expressive parts in body: parts that may not have words and communicate through body. • “Check inside to see if any parts in the body are carrying any burdens in the body related to this memory?” Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

IFS-Informed Phase 7 (Fatter, 2023)

EMDR (Shapiro, 2018):

• Closure

IFS: • For incomplete sessions, retrieve parts to be with Self. • If complete: Integration. Appreciation to protectors, invitation for protectors to witness unburdened exile, invitation for protector unburdening. • If complete: When protectors took on burden/role may become a new target for Phase 4.

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IFS-Informed Phase 8 (Fatter, 2023)

EMDR (Shapiro, 2018):

IFS:

• Reevaluation

• Checking in with any protector parts. • Which parts now are connected to the target memory?

Case Example: Complex PTSD

3 yrs

Questions? Stay in touch: Daphne Fatter, Ph.D. • info@daphnefatterphd.com • https://www.daphnefatterp hd.com/

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References Alter-Reid, K. (2023), “Interrupting and Healing Trans-generational Trauma with EMDR Therapy”. Presented at the 2023 EMDRIA Conference, Washington D.C., August 2023. Amano, T & Toichi, M. (2016). The Role of Alternating Bilateral Stimulation in Establishing Positive Cognition in EMDR Therapy: A Multi-Channel Near-Infrared Spectroscopy Study. PLoS One. 2016 Oct 12;11(10):e0162735. doi: 10.1371/journal.pone.0162735. PMID: 27732592; PMCID: PMC5061320. American Psychological Association (2021). APA Guidelines on Evidence-Based Psychological Practice in Health Care. Retrieved May 26, 2023 from https://www.apa.org/about/policy/psychological-practice-health-care.pdf 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.

References Anderson, F. G. (2021). Transcending trauma: healing complex PTSD with internal family systems therapy. PESI Publishing & Media. Archer, D. (2021). Anti-Racist psychotherapy: Confronting systemic racism and healing racial trauma. Each One Teach One Publications. 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. Ashley. W. & Libscomb, A. (2023) Strategies for implementation of an anti-oppressive, antiracist, intersectional lens in EDR therapy with Black clients. In Nickerson, M. (Ed.) (2023). Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. Springer Publishing Company; 2nd edition. Baldwin, M. & Korn, D. (2021). Every memory deserves respect: EMDR, the proven trauma therapy with the power to heal. Workman Publishing Company: New York, NY. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

References Bartlett A, Faber S, Williams M, Saxberg K. Getting to the Root of the Problem: Supporting Clients With Lived-Experiences of Systemic Discrimination. Chronic Stress. 2022;6. doi:10.1177/24705470221139205 Bongaerts, H. Voorendonk, E. M., van Minnen, A., & de Jongh, A. (2021). Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth. European Journal of Psychotraumatology, 12(1), 1860346. Open access: http://dx.doi.org/10.1080/20008198.2020.1860346 Bongaerts, H., Voorendonk, E. M., van Minnen, A., Rozendaal, L., Telkamp, B. S. D., & de Jongh, A. (2022). Fully remote intensive trauma-focused treatment for PTSD and complex PTSD. European Journal of Psychotraumatology, 13(2): 2103287. Open access: https://doi.org/10.1080/20008066.2022.2103287 Cloitre, M., Brewin, C. R., Bisson, J. I., Hyland, P., Karatzias, T., Lueger-Schuster, B., . . . Shevlin, M. (2020). Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: Response to Achterhof et al., (2019) and Ford (2020). European Journal of Psychotraumatology, 11, 1739873. doi:10.1080/20008198.2020.1739873 Cloitre, M. (2020). ICD-11 complex post-traumatic stress disorder: Simplifying diagnosis in trauma populations. The British Journal of Psychiatry, 216(3), 129-131. doi:10.1192/bjp.2020.43

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References Cloitre, M. (2021) Complex PTSD: assessment and treatment. European Journal of Psychotraumatology, 12:sup1, 1866423, DOI: 10.1080/20008198.2020.1866423 Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. New York, NY: Routledge. 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, p. 81-110. Finley, E. P., Mader, M., Bollinger, M. J., et al. (2017). Characteristics associated with utilization of VA and NonVA care among Iraq and Afghanistan Veterans with Post-Traumatic Stress Disorder. Mil Med.;182(11):e1892–e1903. doi: 10.7205/MILMED-D-17-00074. Floyd, T. (2023). Creating access to IFS training and consultation for bipoc therapists: Black therapists rock leads the way. In Redfern, E. (Ed). Internal Family Systems Therapy: Supervision and Consultation, p.78-93. Routledge.

References Girianto., P. W. R., Widayati., D. & Agusti, S. S. (2021). Butterfly Hug to Reduce Anxiety on Elderly. Jurnal Ners dan Kebidanan, Volume 8, Issue 3, 295–300. 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), 131-144. https://doi.org/10.1111/jmft.2017 Hill, M.D. (2019). Adaptive Information Processing Theory: Origins, Principles, Applications, and Evidence. Journal Evidenced-Based Social Work, 17(3):317-331. doi: 10.1080/26408066.2020.1748155. Epub 2020 Apr 24. PMID: 32420834. 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 Jarero, I. N. and Artigas, L. (Dec. 2022 in Press). The EMDR Therapy Butterfly Hug Method for Self-Administer Bilateral Stimulation. In EMDR Protocols for Prolonged Adverse Experiences. Kluft, R. P. (1988). Playing for time: temporizing techniques in the treatment of multiple personality disorder. American Journal of Clinical Hypnosis, 32, 90-98.

References Korn, D. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research, Vol. 3, No. 4, pp. 264-278. Krauze, P. and Gomez, A. (2013). EMDR Therapy and the use of Internal Family Systems Strategies with Children. In C. Forgash and M. Copeley (Eds.), Healing the heart of trauma and dissociation with EMDR and ego state therapy (pp. 295-311). New York, NY: Springer Publishing Company. Levis, R. V. (2017). Placing Culture at the Heart of EMDR Therapy. In Nickerson, M. I. (Ed.), Cultural Competence and Healing Culturally-Based Trauma with EMDR Therapy: Innovative Strategies and Protocols (pp. 97-112). New York, NY: Springer Publishing Co. Levis, R. V., & Siniego, L. B. (2017). An Integrative Framework for EMDR Therapy as an Anti-Oppression Endeavor. In Nickerson, M. I. (Ed.), Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols (pp. 79-96). New York, NY: Springer Publishing Co. Maxfield, L. (2019). A clinician’s guide to the efficacy of EMDR therapy. Journal of EMDR Practice and Research [Editorial], 13(4), 239-246. http://dx.doi.org/10.1891/19333196.13.4.239 Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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References

Nickerson, M. (2023a). Opening the Door: Exploring social and cultural experiences and building resources – EMDR phases 1 and 2. In Nickerson, M. (Ed.) Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols, (pp. 66-83). Springer Publishing Company; 2nd edition. Nickerson, M. (2023b). Healing and Resilience Building with EMDR Reprocessing: Target Selection and EMDR phases 3 to 6. In Nickerson, M. (Ed.) Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols, (pp. 66-83). Springer Publishing Company; 2nd edition. Novo Navarro P, Landin-Romero R, Guardiola-Wanden-Berghe R, Moreno-Alcázar A, ValienteGómez A, Lupo W, García F, Fernández I, Pérez V, Amann BL. (2018). 25 years of Eye Movement Desensitization and Reprocessing (EMDR): The EMDR therapy protocol, hypotheses of its mechanism of action and a systematic review of its efficacy in the treatment of post-traumatic stress disorder. Rev Psiquiatr Salud Ment (Engl Ed). Apr-Jun;11(2):101-114. English, Spanish. doi: 10.1016/j.rpsm.2015.12.002. Epub 2016 Feb 11. PMID: 26877093. O'Shea Brown, G. (2020). Internal Family Systems Informed Eye Movement Desensitization and Reprocessing An Integrative Technique for Treatment of Complex Posttraumatic Stress Disorder. International Body Psychotherapy Journal, 19 (2), 112-122. Pagani M, Castelnuovo G, Daverio A, La Porta P, Monaco L, Ferrentino F, Chiaravalloti A, Fernandez I, Di Lorenzo G. (2018). Metabolic and Electrophysiological Changes Associated to Clinical Improvement in Two Severely Traumatized Subjects Treated With EMDR-A Pilot Study. Front Psychol. Apr 16;9:475. doi: 10.3389/fpsyg.2018.00475. PMID: 29713297; PMCID: PMC5911467. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

References Penailillo, C. C. (2022). Clinical considerations when treating immigration-based trauma within Latinx clients using EMDR therapy. In M. Nickerson (Ed.), Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy (pp. 259-270). New York, NY: Springer Publishing Company. Parnell, Laurel. (2008). Tapping In: A Step-by-Step Guide to Activating Your Healing Resources Through Bilateral Stimulation. Sounds true. Riemersma, J. (2023). An IFS Shorthand Tool: Move Toward. In J. Riemersma (Ed.), Altogether Us: Integrating the IFS Model with Key Modalities, Communities, and Trends, p. 21-50. Pivotal Press. Robinson, N. S. (2023). Legacy attuned emdr therapy: Toward a coherent narrative and resilience. p. 383-391. In Nickerson, M. (Ed.) Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. Springer Publishing Company; 2nd edition Schwartz, R. C. (1995), Internal Family Systems Therapy. New York: Guildford Press. Schwartz, R. C. & Sweezy, M. (2020). Internal Family Systems (2 nd 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.

References 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) 18311841; DOI: https://doi.org/10.3899/jrheum.121465 Shapiro, R. (Ed.) (2005). EMDR Solutions: Pathways to healing. New York, NY: Norton and Norton Company. Shapiro F. The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. Perm J. 2014 Winter;18(1):71-7. doi: 10.7812/TPP/13-098. PMID: 24626074; PMCID: PMC3951033 Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols and Procedures.(3rd edition). The Guilford Press.

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References Sinko, A. (2017). Legacy burdens. In M. Sweezy & E. L. Ziskind (Eds.), IFS: innovations and elaborations in Internal Family Systems Therapy (p.p. 164-178). Taylor and Francis. Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons Inc. Sykes, C., Sweezy, M. & Schwartz R. C. (2023). Internal Family Systems: Therapy for Addictions: Trauma-informed, Compassion-Based Interventions for Substance Use, Eating, Gambling and More. PESI. Twombly, J. H. (2013). Integrating IFS with phase-oriented treatment of clients with dissociative disordered clients. Internal Family Systems Therapy: New Dimensions, 72. doi: 10.1037/e608922012- 134. 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. van der Kolk, B. A. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books. Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

References Williams, M., Osman, M., & Hyon, C. (2023). Understanding the Psychological Impact of Oppression Using the Trauma Symptoms of Discrimination Scale. Chronic Stress (Thousand Oaks),7:24705470221149511. doi: 10.1177/24705470221149511. PMID: 36683843; PMCID: PMC9850126. Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., & Kiernan, M. D. (2018). The Use of EyeMovement Desensitization Reprocessing (EMDR) Therapy in Treating Post-traumatic Stress Disorder-A Systematic Narrative Review. Frontiers in psychology, 9, 923. https://doi.org/10.3389/fpsyg.2018.00923 Twombly, J. (2022). Trauma and Dissociation Informed Internal Family Systems: How to successfully treat complex PTSD, and dissociative disorders. Yosso, T. J. (2005). Whose culture has capital? A critical race theory discussion of community cultural wealth. Race, Ethnicity, and Education, 8(1), 6991. https://doi.org/10.1080/1361332052000341006 Copyright © 2023 Daphne Fatter, Ph.D. Do Not Copy Without Permission

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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.

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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.

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Strengthen Executive Function, Attention, Memory, Response Inhibition & SelfRegulation in Children & Adolescents Lynne Kenney, PsyD Pediatric Psychologist Wellington Alexander Center Scottsdale, Arizona

We are Here to Shift the Trajectory of Children’s Learning

Disclosures Dr. Kenney is a pediatric psychologist in the State of Arizona practicing on an intensive language and executive function treatment team at Wellington-Alexander Center for the treatment of Dyslexia, ADHD, Dyscalculia, and Dyspraxia. As the author and co-author of five books, Dr. Kenney receives royalties from three publishers. Dr. Kenney develops executive function curriculum and cognitive-motor physical activity programs that are used worldwide. She is the creator of the CogniSuite™ Collection and co-creator of CogniMoves® with Benjamin Bunney, MD along with a team of neuroscientists, educators, and animators. Dr. Kenney co-developed the first executive function and self-regulation roll-out mat, Cognitivities™ with Fit and Fun Playscapes. Dr. Kenney’s primary income is from clinical practice, teaching, and product sales. The products mentioned in this presentation are not sponsored. Resources are shared for your benefit and the well-being of those with whom you work.

Scope of Use of Content The content in this professional training consists of proprietary content, published, copyrighted, trademarked material, images and concepts from myself, other scientists, publishers, and authors. It is my intention to properly source and cite each reference. As a course attendee, you have consent to educate and inform your colleagues, patients and students using the materials provided. You may not publish the content, put it online, or share it in any form without the original citations. Some of the videos that you will see were filmed for training and cannot be shared. Your respectful use of this work is appreciated. If you ever wonder about consent for use let me know, I will be honored to speak with you, lynne@ lynnekenney.com.

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Workshop Overview Importance of Executive Function

Executive Function Skill Interventions

The Ready

CogniSuite - Attention, Memory Self-Regulation

To Learn Brain

Tools for Screening & Assessment

Cognitive Skill Coaching

@drlynnekenney lynne@lynnekenney.com

The Morning Program

The Importance of Executive Function

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Executive Function Predicts Achievement For many students, Executive Function Skills and Self-Regulation are more powerful predictors of reading and math achievement than IQ or Socio-Economic Status. Empirical research demonstrates that the development of executive functions during childhood plays a central role in school readiness, academic achievement, social-emotional development, and life-long success. See Mulder, et al. 2017; Blair and Razza, 2007; Bull et al., 2008; Clark et al., 2010; Geary et al., 2012; Cortés Pascual et al., 2019; McClelland et al., 2021.

Executive Function is Central to Immediate & Life-Long Success •Increased school readiness •Better performance in reading and math •More stable relationships

•Better job performance •Better productivity •Better physical health •Higher graduation rates

•Less risk-taking behavior

•Higher income

Cognition is Action Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. Cognition is the ability to perceive and respond, process and understand, store and retrieve information, make decisions, and produce appropriate social responses.

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What is Executive Function? Executive Function is a collection of self-regulatory control processes that are divided into core domains of working memory, inhibition, control of attention, and cognitive flexibility. Healthy executive functioning helps us to be adaptive prosocial human beings. Executive Function includes metacognitive and functional abilities that increase awareness and conscious control of our thoughts, feelings and actions.

What are Executive Function Skills? Executive function skills are essential for planning, executing, and monitoring goaldirected behavior, and are therefore central to problem-solving and learning. EF is associated with core academic achievement in reading, math, science, and social studies for typically developing children as well as those with special needs.

Working Memory: the ability to hold information in mind for recall and application Cognitive Flexibility: the ability to think about something in multiple ways, flexibly shift the focus of one’s attention, and generate multiple solutions to a problem Inhibitory Control: the ability to inhibit fast and unthinking responses to stimulation

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The Ready To Learn Brain

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When you say that a child is ready to learn, what does that mean to you? ________________ ________________

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Fitness & Standardized Testing: Physically fit children demonstrate greater attentional resources, have faster cognitive processing speed, and perform better on standardized academic tests. Source: Educating the student body.

Fitness, Cognition & Achievement

Fitness & Executive Function: A growing body of research in children and adults indicates that higher levels of fitness are associated with better control of attention, memory, and cognition (Colcombe and Kramer, 2003; Hillman et al., 2008; Chang and Etnier, 2009). Fitness & Cognitive Efficiency: The cognitive efficiency seen in higherfit children, is a predictor of arithmetic and reading aptitude independently of IQ and school grade (Hillman et al., 2012).

Fitness & Mental Health: Fitness is also associated with less depression and anxiety, (Kandola et al., 2019).

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The Learning Brain Source: https://www.hydrocephalusscotland.org.uk/content/cognition/

Source: https://www.the-scientist.com/features/the-multitasking-cerebellum-roles-in-cognition-emotion-and-more-70349

Cerebellum The cerebellum is the powerhouse of the connections between the cognitive and motor systems. The cerebellum only accounts for about 10 percent of your brain’s total size. Yet is contains up to 80% of the brain cells in your brain. The cerebellum is involved in the major brain structures that process language, motor and cognitive skills. In fact, the cerebellum is connected to every area of the cortex except the parts of the occipital lobe where low-level visual processing occurs. The cerebellum is responsible for balance, coordinating motor movements, visual control, language processing, and cognition. The cerebellum determines verbal fluency (both semantic and formal) expressive and receptive grammar processing, the ability to identify and correct language mistakes, and writing skills, Starowicz-Filip et al. 2017.

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Executive Functions have been shown to predict school readiness in young children (Blair & Diamond, 2008; Roebers et al., 2014), and are consistently reported to robustly predict academic achievement (Bull, Espy, & Wiebe, 2008; Schmidt et al., 2017; Viterbori, Usai, Traverso, & de Franchis, 2015), cited in Schmidt et al, 2020. Children and youth who have higher levels of aerobic fitness are generally healthier and perform better on tests of executive functioning and academic achievement, Graham, 2021. Coordinative and team interventions with cognitive and motor components are currently seen to have the greatest impact on executive functions, Ferreira-Vorkapic et al. 2021. The physical activities that best engage executive functions are those with increasing cognitive demands, Schmidt et al. 2020. Aspects of physical fitness are also intricately linked to overall health, executive functioning, and academic achievement, Graham, 2021. Increased sedentary time during early childhood has been negatively associated with children’s cognitive and academic skills, Carson et al., 2015.

Let’s Alert Our Brains with a Movement Snack

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Play Builds Cognition

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RECESS

Executive Function Screening & Assessment

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Co-Existing Conditions More than 80% of the population diagnosed with ADHD has a comorbid condition, Lino & Chieffo, 2022. Patients with ADHD often have difficulties in coordination and motor programming just as children with DCD show greater impulsivity and difficulties in inhibitory control, Lino & Chieffo, 2022. Nigg et al., 2005 observed that almost 80% of children with ADHD exhibited a deficit in at least one EF, while this only occurred in 50% of children with typical development (TD). 50% to 80% of children with ADHD or Dyslexia have co-existing diagnoses with 25%40% meeting criteria for both ADHD and Dyslexia, Boada et al., 2012. Developmental coordination while existing in 5-6% of the population exists at substantially higher rates 50%-80% in children with ASD, ADHD and Dyslexia.

Executive Function impairments are observed in neurodevelopmental disorders, such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Specific Language Impairment (SLI), developmental coordination disorder, and dyslexia. When we improve executive function skills in children with learning, attention, and developmental challenges we improve their lifelong success. See: Center on the Developing Child at Harvard University, 2011; Blair & Razza, 2007; Benson et al, 2013; Diamond & Ling, 2016; Masten, et al. 2012; Obradovic, 2010 (as cited in Zelazo, et al. 2016); Scionti, et al. 2019.

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RLRLRLRL RRLLRRLL RLRRLRLL RLRRLRLL

Developmental Domains Precede Learning

50th

25th

Sensory-Motor

Language

Cognition

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Flanker

Source: NIH Toolbox

Source: Neurocognitive Mechanisms of Attention, 2021

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EF Go Pro

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12-Year-Old Gifted Boy

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Here are links to the cognitive task videos BART https://www.brainturk.com/bart Flanker https://youtu.be/x2NvYsswIto NIH Task Descriptions https://www.nihtoolbox.org/domain/cognition/ Stop Signal Task https://youtu.be/LMCHacP3eXI STROOP https://youtu.be/EGpzftQf8oI

The Afternoon Program

11/23/23

Executive Function Skills Interventions

11/23/23

Cognitive-Motor Interventions to Strengthen Executive Function & Self-Regulation

We Are Musical!

A systematic review of the research suggests that short bursts of fine and gross motor coordinated bilateral physical activity may improve attention, processing speed, and focus, van der Fels et al. 2015. In a systematic review of research studies on the impact of physical activity on attention, deSousa et al. 2018 observed that continuous exercises that required greater cognitive involvement like activities with coordination and balance were related to a better performance during attention-demanding tasks than continuous exercises with fewer or no cognitive challenges (Budde et al., 2008; Palmer et al., 2013). Bonacina et al. 2019 reported the use of clapping in time training as a way to possibly affect a broad spectrum of rhythmic abilities that are linked to language and literacy processes.

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Foundational Lessons

•Can Everybody Count? •Can Everybody Clap? •Can Everybody Pause? •1 2 3 Something

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Don’t Forget to Pause

11/23/23

SELF-REGULATION

Self-regulation is generally defined as the ability to manage one’s thoughts, behaviors, and feelings to achieve goal-directed behaviors. Self-regulation is conceptualized broadly to include cognitive processes (executive function), behavioral self-regulation and emotional regulation, Korucu et al., 2022; McClelland et al., 2018.

11/23/23

Self-regulated learners are more engaged in the learning process and demonstrate better academic performance. They exhibit increased focus, attention, and persistence in completing tasks, Wang, 2021. Selfregulation skills are positively correlated with improved reading and math achievement, as well as higher grades in various academic subjects, Zimmerman & Schunk, 2011.

• In practice, self-regulation can be seen as one’s ability to manage their physiological state to maintain balanced internal energy, appropriate motor tempo, and modulated rate of verbalizations. • When self-regulated, children use their cognition to keep themselves calm, emotionally even, and able to effectively respond to expectations and task demands in the moment. • Educators who teach learners self-regulation are more successful at fostering educational success, engagement, and continuous learning, Brenner, 2022.

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Self-Regulation and Response Inhibition are about Learning the “Felt-Sense” Tempo of Slowing Down

Slow 50-85 BPM Quick 85-120 BPM Fast 120-160 BPM

TIGER UNICORN WATERMELON

11/23/23

Cognitive Skill Coaching Interventions

11/23/23

ATTENTION

11/23/23

• Alerting - Moving to a state of cognitive readiness. • Selecting - Moving one’s attention and focus to a specific target stimulus. • Attending - Directing meaningful energy and attention to a specific target stimulus. • Sustaining - Maintaining attention on a specific target stimulus, long enough to take action on it. • Monitoring Drift - Observing the mind becoming off-task. • Re-alerting - Bringing attention back online. • Re-Selecting - Shifting attention from one stimulus to another with purpose or intent.

§ What is attention? § What makes it easy to pay attention? § What makes it difficult to pay attention? § What are the parts of the attention cycle? § How do you turn on your attention engine? § What helps your attention engine run smoothly? § What does it mean to be alert? § When does your attention need a break? § What makes your brain drift? § When you drift where do you go? § What distracts you? § What helps you remain focused? § What do you tell yourself when you brain needs a break? § How long do you think a brain breather should last? § How do you re-alert your attention? § What do you say to yourself to re-alert your attention? § Are there ways we, as a class, can help one another remain alert?

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https://www.meludia.com/en/

https://brainleaptech.com/

Meludia

11/23/23

WORKING MEMORY

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Across

Over

Diagonal

EMOTIONAL REGULATION

11/23/23

2023-11-06

Navigating Addictions: Practical Interventions to Promote Healing & Recovery (Part 1)

Dr. Carissa Muth, R.Psych (AB and BC)

Defining Addictions DSM-5 - Substances and Gambling Criteria (at least 2 in 12 months) • Larger amounts or over longer period of time than intended • Persistent desire or unsuccessful efforts to cut down or control use • A great deal of time is spent in activities necessary to obtain substance • Craving or strong urge to use • Failure to fulfill major role obligations

• Continued use despite persistent social or interpersonal problems • Important activities given up because of use • Recurrent use in situations in which is it physically dangerous • Continued use despite knowledge of having recurrent problems • Tolerance • Withdrawal

Defining Addictions • Excessive habits of everyday life • Dynamic • View behaviour as ego syntonic when it is not • Not strictly due to neuroadaptation

2023-11-06

Model of Addictions •

Earliest models of addictions (1812, 1891) Explain addiction as excessive behaviour patterns from a moral turpitude that requires values conversion and piety.

•

Alcoholics Anonymous Disease or illness model that consider excessive behaviour as a chronic, fundamental disorder for which there is no cure other than abstinence.

•

Biological Model Person has no control, shifts in the reward cycle.

•

Psychodynamic Addiction as adaptive response, keep people from regressing to a more primitive state, self-medication.

History of SUD Opium used medically and spiritually by Greeks

Opium becomes widespread in

Bowrey notes firsthand account

Europe, Middle East, and North

of Cannabis used in Western

Africa

World

10,000

2,000

700

1600s

1700s

1900

Medical marijuana used by

Agapios writes excess alcohol

United States attempts to reduce

Chinese Emperor, Shen

harmful and causes medical

drug trade with opium traffic

Neng

issues

History of SUD Addict begins to be commonly used

APA first classifies Alcoholism and Drug USA Prohibition

to describe someone with an

Addiction under Sociopathic Personality

addiction

1900

Disturbances in DSM-I

1900

Racial stereotypes surrounding marijuana use are prominent

1920 -1935

1935

1952

Alcoholics Anonymous founded

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Biopsychosocial Model • Considers the complexity of addictions • Constellation of factors rather than one cause for addictions • Biological • Psychological • Social

Etiology - BIOLOGICAL 40-60% Biological Factors Epigenetics Cascade Model

Photo Credit: National Institute of Health

2023-11-06

Etiology - SOCIAL

Attachment

Loneliness

Social Learning Theory

Etiology - PSYCHOLOGICAL Comorbidity Emotional Regulation Development

Adverse Childhood Experience (ACE) Study • Higher ACE Score = Great risk of addiction • Higher ACE Score = Lower resilience • Resilience mitigates drug use • Building resilience

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Adverse Childhood Experience (ACE) Questionnaire

Schemas • Patterns of thinking and behavior that are used to interpret • Maximum neurons at 3 years old • Pruning for efficiency • Chronic stress causes excess pruning • Self-protection and survival • Narrative therapy and challenging schemas

Desensitization • Maladaptive cognitive appraisals • Every act of recall is also potentially an act of modification • Learning safety • Prolonged Exposure Therapy

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Meaning Boredom

Escape

Passion

Addiction as a Response “Such widespread phenomena as depression, aggression and addiction are not understandable unless we recognize the existential vacuum underlying them.” “When a person can't find a deep sense of meaning, they distract themselves with pleasure.” — Viktor E. Frankl

RELATIONSHIPS

TRAUMA/ PSYCHOLOGICAL SYMPTOMS/ FAMILY CONFLICT, ETC.

GOALS

------------------------------------------------

Alive INTENSITY

SUBSTANCE USE DANGER CONFLICT

2023-11-06

Developing Meaning • Self- awareness • Acceptance of suffering • Relationships • Intrinsic goals

Assessment • Gold Standard

• Distinguish overwhelming impulses versus and unwillingness to resist those impulses

Psychometric Tools • AUDIT Alcohol screening tool, identify potential hazardous use, 10 questions • CIWA Assess severity of alcohol withdrawal • SCID-5 Structured clinical interview for DSM-5 assessment

2023-11-06

Navigating Addictions: Practical Interventions to Promote Healing & Recovery (Part 2)

Dr. Carissa Muth, R.Psych (AB and BC)

Defining Addictions • Excessive habits of everyday life • Dynamic • Interaction of psychological, social, biological, and existential components

Barriers to Treatment • Stigma • Low self-efficacy • Cost • Logistical limitations • Pre-contemplative

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Prochaska and DiClemente, 1983

Inpatient Treatment

Detox

“Pink Cloud”

Stabilization

Dopamine Receptors After Cocaine Addiction

2023-11-06

Post Inpatient Treatment Care

Behavioural Pattern

Stress Management

Difficult Relationships

Community Support Groups

SMART Recovery

Recovery Dharma

Alcoholics Anonymous

Working With Low Motivation • Complexity of motivation • Resistance • Mapping effects of the issue • What does the substance provide you?

2023-11-06

Boundaries

Unhealthy Means of Survival

Not Showing up for Appointments

Family Involvement

Therapeutic Interventions 1. Understanding • What does the substance provide? • How does the client understand their substance use? • Identifying thought distortions Goal: understand the client’s narrative, cognitive schemas, and relationship with their substance

Feedback-Informed Treatment • Evidenced based approach to assess and adapt to client’s feedback in real time in order to improve session outcomes • Based on common factor model of psychotherapy

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Session Rating Scale

Outcome Rating Scale

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Therapeutic Interventions 2. Shifting • Creating alternative stories • Challenging schemas • CBT thought records • Amplified reflection (Motivational interviewing) • Reframing

C B T M odel A pplied to A ddictive B ehaviours

2023-11-06

Therapeutic Interventions 3. Developing a “New Normal” • What gets you out of bed in the morning? • What do you want to live for?

Exploring Meaning Three types of values whereby one can discover meaning: • Creative What the person gives to the world • Experiential What the person receives from the world • Attitudinal Adopting the right attitude of acceptance and taking a stand towards unavoidable suffering

2023-11-06

ACTIVITY

BEAUTY ACCEPTANCE

• Activities that are intrinsically valuable and interesting • Activities that are instrumental in obtaining significant goals • Activities that are self- transcended and directed at serving others Beauty, truth and love joy and wonder Acceptance in suffering

Thank you! Questions?

11/23/23

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)

11/23/23

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.

11/23/23

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.

•

C an still connect w ith others in m eaningful w ay.

•

A dapt to w hat is happening in present m om ent w ith attentiveness and calm ness.

•

If stress occurs, can m anage , continue to breathe , positive self-talk,, etc.

•

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.

11/23/23

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

C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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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C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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

C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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.

11/23/23

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

C o p y r ig h t © 2 0 2 3 D a p h n e F atte r, P h .D .

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).

C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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)

11/23/23

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

C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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.

11/23/23

C O P Y R IG H T © 2 0 2 3 D A P H N E F A T T E R , P H .D .

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.”

C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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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).

C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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

USING SENSORY INPUT TO MANAGE AROUSAL C o p y r ig h t © 2 0 2 3 D a p h n e F a tte r , P h .D .

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 • Corrigan, J.-P., Fitzpatrick, M., Hanna, D., & Dyer, K. F. W. (2020). Evaluating the effectiveness of phase-oriented treatment models for PTSD—A meta-analysis. Traumatology, 26(4), 447– 454. https://doi.org/10.1037/trm0000261 • Courtois, C. A., & Ford, J. D.(Eds.) (2009). Treating complex traumatic stress disorders: Scientific Foundations and Therapeutic Models. The Guilford Press. • Courtois, C.A. & Ford, J.D. (2016). Treatment of complex trauma: A Sequenced, relationship-based approach. The Guilford Press. • Cramer, H., Anheyer, D., Saha, FJ., Dobos, G. (2018). Yoga for posttraumatic stress disorder - a systematic review and meta-analysis. BMC Psychiatry. 2018 Mar 22;18(1):72. doi: 10.1186/s12888-018-1650-x. PMID: 29566652; PMCID: PMC5863799.

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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• Geller, S. M. (2018). Therapeutic Presence and polyvagal theory: Principles and practices for cultivating effective therapeutic relationships. In Clinical Applications of Polyvagal Theory: The Emergence of polyvagal-informed therapies by Porges, S. W. & Dana, D. (Eds.), pp. 106-126. • Gilman, S. G. (2011). “A therapist’s guide using HeartMath tools with clients with post-traumatic stress, addictions, chronic pain, grief and loss.” Retrieved via HeartMath Institute. • Ginsberg, J.P., Berry, M. E. Powell, D. P. (2010). Cardiac coherence and posttraumatic stress disorder in combat veterans. Alternative Therapies in Health and Medicine, 16(4), 52-60. • Harris, M. (1998). Trauma Recovery and Empowerment: A Clinician's Guide for Working with Women in Groups. New York, NY: The Free Press. • Heissel A, Heinen D, Brokmeier LL, et al. (2023). Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression. British Journal of Sports Medicine Published Online First: 01 February 2023. doi: 10.1136/bjsports-2022-106282

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• Herman, J. (1992). Trauma and Recovery: The aftermath of violence— from domestic abuse to political terror. Basic Books. New York, New York. • Huang-Storms, L., et al., (2007). QEEG-Guided Neurofeedback for Children with Histories of Abuse and Neglect: Neurodevelopmental Rationale and Pilot Study. Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience, 10 (4): 3 - 16 • Janet, P. (1973). L’automatisme psychologique. Paris: Societe Pierre Janet. (Original work published in 1889). • Jarero, I. N. and Artigas, L. (Dec. 2022 in Press). The EMDR Therapy Butterfly Hug Method for SelfAdminister Bilateral Stimulation. In EMDR Protocols for Prolonged Adverse Experiences. • Jarero, I., & Uribe, S. (2014). Worst Case Scenarios in Recent Trauma Response. In M. Luber (Ed). Implementing EMDR Early Mental Health Interventions for Man-Made and Natural Disasters: Models, Scripted Protocols, and Summary Sheets. Springer.

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Kirlin, Margaret (2010). Yoga as an Adjunctive Treatment for PTSD in Latina Women: A Review of the Evidence and Recommendations for Implementation (Master's thesis, Pacific University). Retrieved from: http://commons.pacificu.edu/spp/133

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Kluetsch, R. C., Ros, T., Théberge, J., Frewen, P. A., Calhoun,V. D., Schmahl, C. G., . . . Lanius, R. A. (2014). Plastic modulation of PTSD resting-state networks and subjective wellbeing by EEG neurofeedback. Acta Psychiatrica Scandinavica,130(2), 123-136. doi:http://dx.doi.org/10.1111/acps.12229

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Korn, D. & Leeds., AM. (2002). Prelimiary Evidence of Efficacy for EMDR Resoruces Development and Installation in the Stabilization Phase of Treatment of Complex postraumtic stress disorder. Journal of Clinical Psychology, 58(12), 1465-1487

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Levine, P. A. (2018). Polyvagal Theory & Trauma. In Clinical Applications of the Polyvagal Theory: The emergence of polyvagal-informed therapies. p. 3-26. Porges, S. W. & Dana, D. (Eds). New York: W.W. Norton & Company.

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Levine, P. A. (2010). In an unspoken voice: How the body releases trauma and restores goodness. North Atlantic Books.

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Ogden, P., K. Minton, C. Pain, Trauma and the Body, Norton, 2006.

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Parnell, Laurel. (2008). Tapping In: A Step-by-Step Guide to Activating Your Healing Resources Through Bilateral Stimulation.

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Petrosino NJ, Cosmo C, Berlow YA, Zandvakili A, van 't Wout-Frank M, Philip NS. Transcranial magnetic stimulation for post-traumatic stress disorder. Ther Adv Psychopharmacol. 2021 Oct 28;11:20451253211049921. doi: 10.1177/20451253211049921. PMID: 34733479; PMCID: PMC8558793.

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• Rhodes, A.M. (2015). Claiming Peaceful Embodiment Through Yoga in the Aftermath of Trauma Complementary Therapies in Clinical Practice, 21(4), 247-256. •

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TRAUMA-FOCUSED DBT

TARGETING THE DBT BIOSOCIAL MODEL Eboni Webb, PsyD, HSP

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• Understand DBT in the context of the biosocial model regarding

pervasive emotional dysregulation disorders • Understand the impact of trauma on the developing mind • Develop a conceptualization plan that focuses on key biological

and attachment factors within the framework of DBT

LEARNING OBJECTIVES Targeting the Biosocial M odel

The Biosocial Model of Emotional Dysregulation

BORDERLINE PERSONALIT Y DISORDER

Key Characteristics

Attachment Disturbances

Pattern of Impulsivity

Instability in interpersonal relationships

Instability in life

Hypersensitive to abandonment

Unstable self-image and emotions

Pattern of undermining success in relationships

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OVERVIEW •

Clients suffer from emotional vulnerabilities

•

Emotional vulnerabilities can come from many sources (e.g., attachment issues, loss, trauma), but is often assumed to be biological

•

Chronic and consistent invalidation exacerbates emotional vulnerabilities

•

An ongoing, reciprocal relationship exists between emotional vulnerabilities and environments

THE BIOSOCIAL MODEL

•

Em otional vulnerabilities are characterized by: -

Em otional sensitivity

Em otional reactivity

Slow return to em otional baseline

•

Over tim e em otions get sensitized, leading to a “kindling” effect

•

This em otionality (and associated invalidation) is associated with m any problem s (disorders)

•

Em otionality leads to escape and avoidance that leads to chronicity

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Targeting the Biosocial M odel

HYPOTHALAMIC PITUITARY ADRENAL AXIS Open pathway for first 6 months of life

Excessive Cortisol Effects • Neurotoxic to the Hypothalamus • Neuron Death • Clogging of the corpus callosum connecting the left and right hemispheres • Suppression of the immune system

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AMYGDALA: FIGHT, FLIGHT, AND FREEZE Features • Reactionary • Triggers Sensory System (Smell and Touch are the most direct pathways) • Controls autonomic responses

WHAT HAPPENS DURING A STRESS RESPONSE?

Blood Flow Decreases • Frontal Lobe • Nondominant Hemisphere

Sensory System Activates • Hypervigilance • Heightened 5 senses

Blood Flow Increases • Heart • Extremities • Decreases to Gut • Digestive Issues

•

Abuse and neglect

•

Open rejection of thoughts, feelings, and behaviors

•

Making “normal” responses “abnormal”

•

Failing to communicate how experience “makes sense”

COMMON T YPES OF INVALIDATION Targeting the Biosocial M odel

•

Expecting behaviors that one cannot perform (e.g., due to developmental level, emotionality, or behavioral deficits

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Types of Dysregulation

Dysregulation: Learned Behavior

Invalidating Environment

Cortisol Release

Distress Cues Dysregulation

Cortisol=Automatic (Uncomfortable) reaction

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EMOTIONAL DYSREGULATION

Emotional Arousal

Coping-Avoidance Escape Behaviors Heightened Reactivity Innate Sensitivity Time

Hormonal Counter to Cortisol Architect of Regulation

Oxytocin

How Problematic Auto-Regulation is Learned

Oxytocin

Cortisol

SelfSoothe

Stress

Behavior

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TREATMENT TARGETS TO INCREASE OXY TOCIN WITHOUT PROBLEM BEHAVIORS • Hugs

• Make positive eye• Build Positive Experiences

contact

• Sing in a choir

• Self-Soothe

• Breath work

• Give a back rub/foot

rub

• IMPROVE the Moment

• Listen without

• Nonjudgmental Stance

• Positive touch

• Stroke a dog or cat • Perform a generous act • Pray

• DISTRACT

judgment

• Hold a baby

• Mindful Breathing

• Proximity

• GIVE

• Laugh/Dance

Social Engagement System ▫ ▫ ▫ ▫ ▫

Eye-gazing Language Prosody Touch Proximity

Biosocial Theory Coherently Guides Treatment Targets and Strategies

Validation is a primary intervention to: Reduce acute em otionality

Provide gentle exposure to em otions

Provide a corrective validating environm ent (and new learning)

Create a bridge to learning selfvalidation

Open the client up to change interventions

Emotion regulation is taught to: Understand how em otion happen

Reduce vulnerability to intense em otions

Increase opportunities for positive em otions

Assist in stepping out of ineffective m oodcongruent behaviors

Biosocial Theory Coherently Guides Treatment Targets and Strategies

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Mindfulness (non-judgment and acceptance) is taught to: • Reduce amplifying emotions • Reduce escape and avoidance of emotions • Create qualitatively different and effective experience of emotions

Distress Tolerance is taught to: • Provide healthy ways of coping with emotions when needed

Use the theory to conceptualize the purpose of the interventions used

HEALTHY ATTACHMENT

From Bowlby and Beyond

ATTACHMENT GOAL SECURE AND AUTHORI TATI VE PARENTI NG PRODUCES AUTONOMOUS AND I NTERDEPENDENT ADULT S

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ATTACHMENT RULE AT TAC H M E N T I S N OT F I X E D O R A B S O LU T E . G ROW T H A N D CHANGE ARE D R I V E N BY O N E ’ S SEASON OF LIFE.

DEFINITION: ATTACHMENT

SelfConcept

Affect Regulation

Cognition

Behavioral Regulation

“A N I N - B O R N S Y S T E M I N T H E B R A I N T H AT E VO LV E S I N WA Y S T H AT I N F L U E N C E A N D O R G A N I Z E M O T I VAT I O N A L , E M O T I O N A L A N D M E M O RY P ROC ES S ES WI T H RES P EC T TO SIGNIFICANT CAREGIVING F I G U R E S . ” ( B OW L B Y )

How do we live and thrive as humans? (Bowlby to Ainsworth)

Secure Base

Safe Harbor

Proximity Maintenance

Seeking, m onitoring, and attempting to

Fleeing to an attachm ent figure when in

Attunem ent, presence, accountability,

m aintain connection to a protective attachm ent figure.

situations of danger or alarm

direction, protection, correction, and connection.

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A I N S WO RT H & M A I N AND AT TAC H M E N T

Avoidant

Ambivalent

Secure

THE STRANGE SITUATION SECURE ATTACHMENT oReunion behaviors are more insightful than separation behaviors. oImmediate reassurance from the return of their secure base (distress is natural and expected at separation). oReconnection prompts return to independent exploration and play. oChild Behaviors: Flexibility and resilience oSecure Parent = Sensitivity, attunement, acceptance, cooperation and emotional availability

THE STRANGE SITUATION AVOIDANT ATTACHMENT oReunion behaviors are more insightful than separation behaviors. oApparent lack of distress should not be mistaken for calm. Superficial indifference is a trauma defense. oReconnection displays active rejection of bids for connection by parent resulting in limp physical connection. oParent Behaviors: W ithdraw and Rebuff oAvoidant Parent = Inhibited emotionality, aversion to physical contact, and brusqueness

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THE STRANGE SITUATION AMBIVALENT ATTACHMENT oReunion behaviors are more insightful than separation behaviors. Looking for their absent parent even when the parent is present. oTwo presentations: Angry or Passive oReconnection displays overt bids for connection and expressions of rejection (e.g. full-blown tantrums, leaning away, etc.) to implicit bids for solace displayed in helplessness and misery. Lack of exploration. Parent Behaviors: Unpredictable and Intermittently available oAmbivalent Parent = Insensitive signaling, neither verbal or physically rejecting while discouraging autonomy

AINSWORTH & MAIN INFANT TO ADULT

Secure/Autonomous

Preoccupied

Dismissing

Disorganized

ADULT STATE OF MIND WHAT TO LOOK FOR

My parents did the best they could, but they did make mistakes.

My parents just didn’t get me, but I don’t know I guess they tried but they were always trying… .

oSecure: Values attachment, objective, collaborative, consistent even in unfavorable experiences. oDismissing: Inconsistent, high efforts to normalize experiences and relationships, overly generalized and unsupportive or contradictory evidence. oPreoccupied: Fixated on past grievances often appearing angry, passive or fearful. Long winded and still vague in descriptions.

I h a d v e ry

I can’t believe my

e x ce lle n t p a re n ts. V e ry

mother treats me this way after all these years, my kids have it so

n o rm a l ch ild h o o d .

good.

oDisorganized: Lapses in reasoning and coherent discourse especially when discussing trauma, loss, or abuse. Time is fluid.

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S T E P S T O A DA P TAT I O N : L E A R N I N G H OW T O F I T I N YO U R FA M I LY S Y S T E M Intersubjectivity (Trevathen, 1980) Wounding

Intention

Attunement

Communication

Action

Repair

Trauma Mirror Neurons (Gallese, 2007)

Dem ocratic-Authoritative Parenting

Abusing-Authoritarian Parenting

High nurturance, expectations, and control Moderate com m unication

High expectations and control Low nurturance and com m unication

Neglecting-Uninvolved Parenting

Indulgent-Perm issive Parenting

Low nurturance, expectations, control and com m unication

com m unication, low expectations, and control

High nurturance, m oderate

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Family Dialectical Dilemmas Excessive Leniency Fostering Dependence

Pathologizing Normal Behaviors

Limits Presence

Forcing Autonomy

Normalizing Problem Behaviors

Authoritarian Control

SEC U RE C onsistency

B ASE

C onnection

Protection

Parents Inspection

Healthy Attachment

PROX IM ITY M AIN TEN AN C E

SAFE H ARBO R

Em otional Safety

Community

Family

D irection

Body

Social

Mind

ATTACHMENT AND TRAUMA Eboni Webb, PsyD, HSP

11/3/23

What is Trauma?

• Divorce • Prolonged separation from parents and/or siblings • Frequent moves • School transitions • Bullying (Cyber, physical, etc.)

• In utero assaults • Delivery difficulties • Health of both parents during conception • Mental Illness • Abandonment via adoption • Learning difficulties

• Identity disturbances • Racial issues • Inside threats • Sexual assaults • Accidents (falls, vehicle, etc.)

th is y is ? Wh in g pen hap

Wha t can I lear n from this ?

How do I fix th is ?

Prefrontal Cortex Observing Thinking Decision-Making Mid Brain Emotional Center

W il lI su rv iv t h is e ?

Memory

Lower Brain Survival defenses Automatic processes

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The vagus nerve is the largest nerve in the body and controls our body’s ability to detect danger, sense safety, experience rest/relaxation, and connect socially. It is refined through connection from birth and innervation of touch. The Polyvagal Theory (Porges, 2011)

Safe

Danger!

Life Threat

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Attachment vs. Developmental Trauma 46

Parent Attachment Style & Adoption

Parent Attachment Style

Autonomous/Free (Authoritative) Dismissing (Authoritarian/Uninvolved) Entangled (Permissive/Anxious) Unresolved (Authoritarian/Neglecting)

% of Low-Risk Adoption

% of Troubled Adoptions (e.g. trauma, abuse, illness)

Avoidant

20%

42%

Ambivalent

20%

42%

Childhood Attachment Type

American Population %

Secure

15%

Disorganized

1-2%

TCU Institute of Child Development . (Producer). (n.d.). Attachment Dance [DVD]. Available from TCU.

Unraveling the Trauma Bond

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Child Dialectical Dilemmas Increasing Choices Acceptance of Change

Supervising Connected Authoritative

Giving Permission

Validating Stability Keeping their world small

EMOTIONALLY REGULATED

“

We cannot selectively numb emotions, when we numb the painful emotions, we also numb the positive emotions. Brene Brown 51

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Types of Dysregulation

FROM A TRAUMA STATE TO A CLEAR STATE OF MIND……. Sex

Alcohol

SelfHarm IT DIDN’T REALLY HAPPEN

Work Drugs 53

Eating Disorders

A I

U I

NEW SELF

HOPE

L T

IT REALLY HAPPENED

IT REALLY HAPPENED TO ME

N G

S H A

E R

M E

VOICE

HEAL

BODY CENTERED AND GROUNDED

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Repairing the Trauma Bond

Adolescent Dialectical Dilemmas Skill Enhancement

Trust

Transparency Empathic Relational

Suspicion

Privacy Self Acceptance

RESET SURVIVAL DEFENSES

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HYPERAROUSAL

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

HYPOAROUSAL

ORGANIZED STORYTELLING

From Organization to Disorganization Organized Storytelling

Disorganized Storytelling

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How Do We Create Our Stories? ╺

╺

Thoughts Emotions Sensations Urges Movements

How the Brain Organizes Our Experiences

Sensations

Thoughts

Emotions

Urges

Movements

What Does Earned Security Look Like? 63

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Survivors

SECURE BASE

Sponsor

G roup

Safe Housing

Therapist C oaches

PROXIMITY MAINTENANCE

SAFE HARBOR

HEALING

Physician

C ase

Therapy

Family

M anagem ent

Body

HOLISTIC THERAPY

Mind

TRAUMA-FOCUSED DBT: COMMON SURVIVAL RESOURCES AND CRITICAL INTERVENTIONS EBONI WEBB, PSYD

Five Movements Mindfulness

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Learning Objectives ╶

╶

Define internal and external resources. Identify how to develop a toolkit of resources that validate our client’s survival, somatic, and creative resources. Learning how to work proximity maintenance: Restructuring boundaries

╶

Define Prosody: Modulating vocal intensity

╶

Learn how to create a safe therapeutic haven

╶ 67

Learn how to communicate validation: Connection before Redirection

Let’s Practice!

Recall an event that is/was emotionallycharged for you.

Close your eyes and see yourself in the situation with all the emotions and all the details.

Wrap your arms around yourself, head down and allow whatever emotions you have to flow in until you hear the bell chime.

After you hear the chime, sit up and place your hands palms up on thighs.

Practice holding a half-smile.

Eyes will remain open.

7 Lift eyebrows and breathe fully.

8 Continue recalling the emotionallycharged event until you hear the chime again.

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Safe

Danger!

Life Threat

Acute Response to Threat Study Hyperaroused Continuum

Rest (Male Child)

Vigilance (crying)

Resistance (Freeze)

Defiance (posturing)

Aggression (hitting, spitting)

Dissociative Continuum

Rest (Female Child)

Avoidance (Crying)

Compliance (Freeze)

Dissociation (Numbing)

Fainting (checking out, minipsychosis)

Primary Brain Areas

Neocortex

Subcortex

Limbic

Midbrain

Brainstem

Cognition

Abstract

Concrete

Emotional

Reactive

Reflexive

Mental State

Calm

Arousal

Alarm

Fear

Terror

Social Engagement System ▫ ▫ ▫ ▫ ▫

Eye-gazing Language Prosody Touch Proximity

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HYPERAROUSAL

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

HYPOAROUSAL

Window of Tolerance

Hyperarousal-Fight, Flight, Freeze,

Hypoarousal-Dissociation, Numbing, Depression

Sensorimotor Psychotherapy Institute® Sensorimotor Psychotherapy founder, “Pat Ogden

Emotion

Function

Action Urge

Anger

Boundary, Identity, Injustice

Attack, Define a boundary

Disgust Envy Fear Guilt Happy Jealousy Love Sadness Shame

Protect from contamination/influence Obtain something not currently possessed Survival, Life Threat To signal a threat to personal morality Connect with pleasure To signal a threat to an important relationship Connect relationally To signal a loss (relationship or expectation) To signal a threat to social standards/expectations

Reject, Separate Obsess, Aspire Survival Defenses To make amends or apologize Maintain Possess, Posture, Protect Connect, Sustain Isolate, Withdraw Hide, Conform

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Need

Age of Development

Healthy Development

Unhealthy Development

Key Emotions Impacted

Emotions

Threat Response

Fear, Happy, Anger Fear, Jealousy, Love

Survival

0-2

Security

2-3

Pleasure

0-3

Body-Self Development

Body Shame

Shame, Disgust, Envy, Love, Guilt

Affection

4-5

Capacity for love, sense of love and belonging, worthiness

Inhibition from autonomous connection

Love, Anger, Envy, Jealousy

Esteem

5-6

Recognition, Acknowledgement, Self-Acceptance

Lack of trust in self

Sadness, Shame, Guilt

Control

3-7

Choice

Compulsion, Impulsivity

Jealousy, Anger, Fear

Power

Intention

Invulnerability

Envy, Guilt, Fear

Self in Relationship Diffuse Boundaries

Oxytocin

Hormonal Counter to Cortisol Architect of Regulation

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Treatment Targets to Increase Oxytocin Without Problem Behaviors •

•

• •

•

• • •

• •

•

• •

•

• • • •

Signs of cPTSD: What to Look For

SelfInvalidation

•Self-hate/criticism of ethnicity, culture •People-pleasing/assimilation behaviors •Perfectionism/Procrastination/Proving worth

Emotional Vulnerability

•Anger, Bitterness Towards Others •Fragility, Vulnerability

Traumatized Experiencing

•Active avoidance •Passive avoidance, dissociation

How to Help

Self-Invalidation • Modeling and owning failure • Communicating validation

Emotional Vulnerability • Teach culturally-sensitive body positivity and self-care • Create a safe environment for dialogue

Traumatized Experiencing • Model Emotions • Display authentic reactions without minimizing

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Signs of cPTSD: What to Look For

Unrelenting Crises Active Passivity Apparent Competence

• Uncontrollable Events (e.g. COVID-19) • Ongoing televised racial trauma • Constant trauma cues in family of origin

• Willfulness, Demandingness • Helplessness

• Disconnect between verbal and nonverbal behavior • Contextual Competence (mood/situational)

How to Help

Unrelenting Crises • Control the Controllable in the Safe Harbors • Establish curfews and limit access to media outlets without supervision and increase dialogue

Active Passivity • Cheerlead • Encourage problem-solving • Establish deescalating space

Apparent Competence • Highlight effective behaviors observed • Lose the assumption of how the loved one “should” behave in all contexts based upon one.

Whole Body Healing

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th is y is ? Wh in g pen hap

Wha t can I lear n from this ?

How do I fix th is ?

Prefrontal Cortex Observing Thinking Decision-Making

W il lI su rv iv t h is e ?

Mid Brain Emotional Center Memory

Lower Brain Survival defenses Automatic processes

Building the Resource Toolkit

Resource Domains (Ogden & Fisher, 2015) Somatic

Psychological

Spiritual

Relational

Artistic/Creative

Nature

Emotional

Intellectual

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Somatic ▫

Internal

▫

External

Relational Internal ▫ Sense of “love and belonging” (Brown) ▫ Ability to reach out and experience connection ▫ Establishing healthy boundaries

External ▫ Friends ▫ Family ▫ Mentors ▫ Spouses/Partners ▫ Pets

Emotional Internal ▫ Access to the full range of emotions, expressions, and sensations ▫ Ability to modulate high to low arousal ▫ Ability to tolerate intensity of emotionality

External ▫ Relationships to give and receive emotional support ▫ “Sister or Brother”-circles ▫ Activities that elicit high and low emotional arousal

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Intellectual Internal ▫ Creative thinking ▫ Dreaming ▫ Imagination ▫ Learning

External ▫ School ▫ Classes ▫ Study groups ▫ Puzzles ▫ Books

Artistic/Creative Internal ▫ Capacity to access creative processes ▫ Imagination ▫ Vision

External ▫ Art materials ▫ Creative writing groups ▫ Cooking classes ▫ Music (e.g. cds/access to music) ▫ Museums

Material Internal ▫ Ability to work (e.g what I get to do and have to do) ▫ To enjoy the comforts of life ▫ Experiencing pleasure

External ▫ Jobs ▫ Home ▫ Comfortable bedding ▫ Life hacks

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Psychological Internal ▫ Strong sense of self ▫ Self-awareness ▫ Esteem ▫ Compassion ▫ Nonjudgmental ▫ Resiliency

External ▫ Access to a therapist ▫ Workbooks ▫ Manuals ▫ Support groups

Spiritual Internal ▫ Ability to develop connection with a Someone or Something greater than one’s self ▫ Capacity to connect with one’s own spiritual essence

External ▫ Meditation ▫ Contemplative Prayer ▫ Shabbat ▫ Spiritual mentors

Nature Internal ▫ Utilizing your senses to take in the world around you ▫ Sensory bathing

External ▫ Gardens ▫ Parks ▫ Hiking ▫ Plants in the home

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Critical Interventions: Building the Therapist’s Resource Toolkit

How do we embody this as therapists?

Safe Harbor

Proximity Maintenance

Attuned therapists that are skilled

O ffice safety and security, inform ed

Tolerate, M odulate, and C om m unicate

listeners, attuned, present, and activated towards change and challenge

Secure Base

consent, confidentiality, com m unity safety planning and protection

D ifficult Em otions, Feelings, and Sensations as they arise in session.

Boundaries

Authoritative Therapy: Proximity Maintenance

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SelfExpression SelfControl SelfDefinition

100

Boundaries (Limits) Core Assumptions (Pederson, 2011) ╺ ╺

╺

Clients often donʼt recognize boundaries Ineffective boundaries can create dysfunction in relationships Ineffective boundaries can create ineffective responses in therapists Clients want to learn about and practice effective boundaries for themselves Clients need to learn about and recognize the boundaries of others Therapists need to model effective boundaries

101

Boundary (Pederson, 2011) Be aware Observe others Understand limits Negotiate sometimes Differences exist Always Remember your values Your safety first

102

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Boundaries (Pederson, 2011) ╺

╺ ╺

╺

Clients benefit from exercises that help them define their boundaries Clients need education about individual differences Clients often need to radically accept individual differences and to learn not to take differences “personally” (also a boundary) Effective teaching will result in healthier connections with less enmeshment, disengagement, and extremes

103

Prosody Authoritative Therapy: Attuned and Moderate Communication

104

Prosodic Communication

• Pitch • Intonation • Rhythm • Loudness • Tempo • Stress

105

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The Therapeutic Space Authoritative Therapy: Creating a Safe Haven

106

The Therapeutic Space Seating Windows Lighting Smells Fidgets Food Weighted blankets Spacing

107

Safe Spaces to Heal Authoritative Home Life

108

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Healing Environments Windows Lighting Smells Fidgets Food Weighted blankets Spacing Security

109

• Validation is the nonjudgmental acknowledgement of a person’s experience • Validation creates the conditions of acceptance that usually precede change

Validation: The Keys to the Kingdom

• As a rule, start with validating the person, and return to validation when the person is “stuck.”

110

Common Types of Invalidation • Abuse and neglect • Open rejection of thoughts, feelings, and behaviors • Making “normal” responses “abnormal” • Failing to communicate how experience “makes sense” • Expecting behaviors that one cannot perform (e.g., due to developmental level, emotionality, or behavioral deficits

111

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Levels of Validation (Linehan, 1997) • • • • • •

112

VALIDATION PRACTICE “I went to the store yesterday and I saw these Red Hot candies. I completely lost it and forgot what I went into the store to get. It reminded me of when I was little and my mom wanted to teach me about waiting. I had asked for some of those candies and she said no, but when she tucked me in that night, she forced me to eat a huge bag until my mouth and eyes burned. I thought I was past that, but I am having urges to cut myself again. I get so angry with myself. I keep myself from eating. If I had any pills, I’d take them…you know, just to numb out.”

113

In Summary Trauma: Is broad, self-perceived, and activates survival defenses to cope. It can come in multiple forms including single-incidents and developmental. Stress Response: Dysregulation is a learned response that is neurobiologically driven and socially maintained. Attachment: Human survival and attachment is dependent on communication, eye-gazing, and finding a way to “fit.” It is essential when working with trauma to see behaviors as “attachment-seeking behaviors” Whole Body Healing: We must seek healing of the body in order to heal the mind. Our functioning isn’t either or but both and. Complex Treatment Strategies: Treatment must be multifaceted including top-down and bottom-up processing techniques. DBT, EMDR, SP, and somatic therapies must be utilized to address the lasting impact of trauma.

114

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115

Questions?

116

Thank-You • Eboni Webb PsyD, HSP ewebb@webbjamconsulting.com 615-589-1018

The Village of Kairos 1451 Elm Hill Pike, Suite 250 Nashville, TN 37210 367 Riverside Drive, Suite 104 Franklin, TN 37064

117

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Jeff Riggenb ch, PhD

jeffriggenb ch.com

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Why Person lity Disorders re Different 1. Ego-Syntonic 2. Extern l Locus of Control 3. Perv sive 4. Enduring vs. Episodic

5. In lexible

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Evidence - B sed Tre tments 1. Di lectic l Beh viour Ther py 2. Schem Focused Ther py 3. Systems Tr ining for Emotion l Predict bility nd Problem-Solving (STEPPS)

4. Ment lis tion - B sed Tre tment 5. Tr nsference - Focused Psychother py

6. Good Psychi tric M n gement

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Integr ted Evidence - B sed Model

Results

Actions

Feelings

Thoughts

Events

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Motiv tion l Skills!

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Motiv tion l Skills Pre-Contemplation

Preparation

Maintenance

I—————I—————I—————I—————I

Action

Contemplation

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Expressions of Concern

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Pros nd Cons

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Integr ted Evidence - B sed Model

Results

Actions

Feelings

Thoughts

Events

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Mindfulness

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Mindfulness Exercise

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Mindfulness

• Being present in the moment focusing on the here & now in a non judgmental manner

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Mindfulness St tes of Mind

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Logic l Mind

• Logical part of brain • Prefrontal cortex Involved • Pros & Cons

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Mindfulness Emotion Mind

• Emotionally Flooded • More Reactive • More Impulsive

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Mindfulness Wise Mind

• Acknowledge feelings and at the same time able to process - acting a way consistent w goals & values

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Go ls of Mindfulness

• Experience and Learn that tolerable and way out of painful emotion is a willingness to relate to them

• Change qualitative relationship to emotions…not right or wrong way to feel in given situations

• Decrease pace of Cognitions

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Grounding Exercise 5 Things you can See 4 Things you can Touch/Feel 3 Things you can Hear 2 Things you can Smell

1 Thing you can Taste

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Emotion Regul tion

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Go ls of Emotion Regul tion

• Reduce vulnerability to negative emotions • Decrease acting out on emotions • Decrease emotional intensity experienced

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Decre sing Vulner bility to Neg tive Emotions PLEASE MASTER Skills P L E A S

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Decre sing Vulner bility to Neg tive Emotions PLEASE MASTER Skills

Build Master(Y) • Get good at something • Feel competent • Build positive experiences • Choose activities/people that will produce positive emotions

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Emotion Regul tion Principles

• Emotions education • Types of emotions • Intensity of emotions • Function of emotions/Pros and cons of emotions

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Emotion Educ tion

• Anxiety = Risk/Resources • Depression - Selective Abstraction of Negative Data

• Anger - Values Violation/“Shoulds”

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Opposite Action

https://www.youtube.com/watch?v=SclV-UWM4Gw

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Opposite Action

• Anxiety • Depression • Anger

• Guilt/Shame

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Distress Toler nce

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Distr ction Techniques

• Distraction Technique - any coping skill that inherently requires thought

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Distr ction Techniques 1. Take a hot bath 2. Paint 3. Go for a walk 4. Play a game on my phone 5. Go to a club 6. Stretching exercises 7. Practice Karate/Martial arts 8. Lift weights 9. Play with yarn/stressball

10. Call a friend

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Wise Mind Accepts

A C C E P T

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Improve the Moment

I M P R O V

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - VACATION

https://m.youtube.com/watch?v=pDKiMYgdxSs

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Improve the Moment

I M P R O V

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Soothing Str tegies - Eng ging the Senses

1. Vision 2. Hearing 3. Smell 4. Touch

5. Taste

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Distress Toler nce - Soothing Str tegies - 3 Choices of R dic l Accept nce

• “Pain is inevitable, su ering is optional” 1.Change the situation (if you can) 2. Accept (if you can’t)

3. Stay Miserable

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

DBT Skills - Interperson l Effectiveness Skills

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Interperson l Effectiveness Skills 0% 25% 50% 75%

100%

Intimacy = “Into-Me-See”

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Interperson l Effectiveness Skills - 3 Types of Effectiveness

1. Objective Effectiveness 2. Rel tionship Effectiveness

3. Self-Respect Effectiveness

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Interperson l Effectiveness Skills - Objective Effectiveness

D E A

Question: Wh t is My Go l?

R M A a

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Interperson l Effectiveness Skills - 3 Types of Effectiveness

G Question: How do I w nt the other person to feel bout me fterw rd?

I V

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses DBT Skills - Interperson l Effectiveness Skills - 3 Types of Effectiveness

F Question: How do I w nt to feel bout myself fterw rd?

A S

T a

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT Skills

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses St nd rd CBT Skills 1. Restructuring Cognitions 2. Rel tionship Aw reness nd Problem-Solving 3. Identity Work

4. Continuums

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT Skills - Cognitive Restructuring - Identifying nd Responding to Autom tic Thoughts

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses St nd rd CBT Skills - Restructuring BPD Autom tic Thoughts

• “Because he is late coming home, he is probably leaving me.” • “Since she betrayed me once, I can never trust her again - she really isn’t even worth talking to again.” • “If I cut myself, he will not leave me.” • “If I tell him everything about me on the rst date I can test him to nd out if he’s really interested.” • “Since she pissed me o , I have to quit. I can’t work with someone like her.” • “It’s ok to cut myself, because cutting is better than other things I could do.”

The Personality Disorder Toolbox: St nd rd CBT Skills Thought Log AUTOMATIC THOUGHT

RATIONAL RESPONSE

St nd rd CBT Skills - Restructuring BPD Autom tic Thoughts

Handout 1.3 – Thought Log

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT Skills - Restructuring P r noid Cognitions: Considering Altern tive Expl n tions

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT Skills - Restructuring Perfectionistic Thoughts

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT - Identity Work

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT - Identity Work

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT - Cognitive Continuums

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses St nd rd CBT Skills - Continuums

“Since my parents “Since mom is critical and have $ and help nosy and drinks too much I—————-———-————I—————————————I me, they have it

I don’t know if I can be

in her life anymore.”

completely all together.”

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses St nd rd CBT Skills - Continuum C rd

“Mom is not perfect…she can be critical and nosy and aggressive and she drinks too much…but she has done a lot right as a parent over the years – even though some of her behaviors are unacceptable, I know she still loves me and I can still love her”

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

St nd rd CBT Skills - Continuum C rd

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Focused Skills

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Beck’s 3 Are s of Core Beliefs

1. Beliefs about self 2. Beliefs about others 3. Beliefs about the world

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Core Beliefs/Schem s

• Term “schema” Coined in 1926 by Piaget - “Structures that integrate meaning into events • Beck - “Cognitive structures that organize experience and behavior”

• Landau & Goldfried - “mental lters that guide the processing of information”

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem /Belief Modi ic tion Skills

Schema Psychoeducation Schema Modi cation Data Logs Internalisation Exercises

1. 2. 3. 4.

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Psychoeduc tion

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Core Beliefs/Schem s

Judith Beck,

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Psychoeduc tion

• Domain #1: Disconnection and Rejection Abandonment Mistrust Defectiveness Emotional Deprivation

Social Isolation

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Psychoeduc tion

• Domain #2: Impaired Autonomy & Performance Dependence Vulnerability Enmeshment

Failure

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Psychoeduc tion

• Domain #3: Impaired Limits • Entitlement/Grandiosity

cient Self-Control

ffi

• Insu

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Psychoeduc tion

• Domain # 4: Others Directness • Subjugation • Self-Sacri

• Approval Seeking

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Psychoeduc tion Domain #5: Overvigilance • Negativity • Emotional Inhibition • Unrelenting Standards

• Punitiveness

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Modi ic tion

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Schem Focused Skills - Belief Modi ic tion Protocol

Identify the Maladaptive Belief Identify Alternate Adaptive Belief Rate Baseline Believability Interventions Rate Believability at Regular Intervals

1. 2. 3. 4. 5.

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Schem Focused Skills - Belief Modi ic tion Protocol

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

D t Logs

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Intern lis tion Exercises

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses Intern lis tion Exercises - Adding

“But”

Evidence Supporting Adaptive Belief: “Took initiative to make dinner for my husband and kids”

Discounting “But”: “But its no big deal – all good mothers do it.”

Add a “But”: “But I did something all good mothers do”

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Integr ted Skills

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Cognitive Beh viour l Ch in An lysis

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Integr ted Skills

1. CB Chain Analysis 2. Integrated Case Study

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Cognitive Beh viour l Ch in An lysis

Results

Actions

Feelings

Thoughts

Events

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Cognitive Beh viour l Ch in An lysis - St nd rd Ch in

• link 1: What made you vulnerable • Link 2: What was the trigger • Link 3 : What was the target behavior

• Link 4 : What were the results

The Personality Disorder Toolbox:

Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Integr ted Skills

1. CB Chain Analysis 2. Integrated Case Study

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Integr ted C se Study

The Personality Disorder Toolbox: Integr ted C se Study - Key Cognitions, Beliefs

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 I was dead (never born)”

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

• Dependent Entitlement

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Integr ted C se Study - D t Log

The Personality Disorder Toolbox: Pr ctic l Str tegies for Meeting the Ch llenges of Your Most Dif icult C ses

Integr ted C se Study - Schem Fl shc rd

LET’S CONNECT! Website: clinicaltoolboxset.com Email: jeff@jeffriggenbach.com Facebook:

DrJeff Riggenbach

• Bro d, comprehensive theme or p ttern • Comprised of memories, cognitions, emotions, bodily sens tions

• Developed in childhood, el bor ted in dulthood

THANK YOU!

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

ag a r gre ev ssi olu on 8o , d na ep ry res ap sio pro n a ac nd h t su o NEUFELD’S TRAFFIC CIRCLE MODEL OF icide

frustration

Gordon Neufeld, Ph.D.

Clinical & Developmental Psychologist Vancouver, Canada

THE UNTOLD STORY OF FRUSTRATION

Becoming Acquainted - is one of Nature’s most powerful and primordial instruments of CARE

- is BLIND and IMPULSIVE if not felt, which can be most (if not all) of the 'me

- comes into existence when things aren’t working, and s'cks around seeking for resolu'on of some kind

- is typically perceived as a NEGATIVE and unnecessary emo'on and therefore not always invited to exist

- serves ATTACHMENT ﬁrst and foremost as aRachment is what most needs to work

- is rou'nely VILLIFIED for the way it expresses itself when its purposes are thwarted - has many and diverse OFFSPRING involving cogni'on & behaviour, which oOen tend to camouﬂage its existence

- has a MIND of its OWN, bent on eﬀec$ng change when sensing disas'sfac'on, but not at all inclined to consult with higher mental processes

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Becoming Acquainted S SU UM IMP ICID U A T FRU GUILT LSES L TR AN

STR A DEPBASEDTIONRES SIO ELFENS T SIV EN SES EM OB PROV ANGE R IMV

IOLENC E ION G G A RESS SELF CK A ATT

EMOTIONAL FIXES FOR ATTACHMENT DISTRESS

Fixes &closure Fixations separa$ontriggered

PURSUIT

FRUSTRATION

ALARM

change

cau$on

FIGHT

FlIGHT

Attachment’s Emergency First Aid Team

-P

R LA

-A

UR SU IT -

- FRUSTRATION -

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

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

EMOTIONAL FIXES FOR ATTACHMENT DISTRESS closure

COMMON MISTAKE Displacing frustra8on to another 8me and place by responses that intensify either ALARM or PURSUIT.

separa$ontriggered

PURSUIT

FRUSTRATION

ALARM

change

cau$on

e ms irritability eng s antru elf-p t rev ds self-blame unis hme nt BEHAVIORAL hos8 sults AGGRESSION lity in DERIVATIVES OF m impa8ence s g a c r g FRUSTRATION a s fyin n 8 h VIOLE iVn self-a jus8 NCE ﬁgh g Tack COGNITION-

foul

BASED DERIVATIVES OF FRUSTRATION

(ie, secondary emo8on)

wor

ANGER

PRIMAL EMOTION

GUILT

SHAME

judgements regarding whose fault

FRUSTRATION triggered by thwarted proximity

CHALLENGE to see through the distrac8ng deriva8ves of frustra8on to the emo8on itself and its typical roots in aTachment distress

PRIMARY CAUSE OF FRUSTRATION

- experienced only by humans

- experienced by all mammals

- triggered by perceived injus'ce

- evoked by something not working

- a SECONDARY emo'on involving - a PRIMAL emo'on that can exist without thinking or feeling cogni'on and consciousness - triggers impulses to assign blame - triggers impulses to eﬀect change, and if thwarted in this work and and seek jus'ce (eg, get even, the fu'lity not felt, in aRacking exact revenge, seek an apology) energy and impulses - focusing on anger including confron'ng it, interferes with resolving underlying frustra'on

- focusing on frustra'on, even if anger exists, best sets the stage for healthy resolu'on

Anger eclipses and camouflages frustration and distracts from its resolution

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration A STORY OF ALTERNATE OUTCOMES

• demanding & commanding • bossing and controlling

OTHERS

• exposing one’s neediness • advising and confron'ng • construc'ng & problem solving • planning and scheming • orchestra'ng & organizing

THINGS

• controlling and manipula'ng

• improving one’s self • adjus'ng & accommoda'ng

SELF

• trying harder to make things work • sacriﬁcing self to make things work

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration A STORY OF ALTERNATE OUTCOMES

• holding on to good experiences

• geYng one’s way all the 'me

• altering 'me or reality or the past

• keeping siblings from being born or sending them back

• altering circumstances or another’s character or decisions

• choosing one’s parents or keeping them together • making things work that won’t

• keeping bad things from happening, including loss and dying

• altering the ‘givens’ • avoiding upset

• defying the laws of nature

for spontaneous transforma$on to happen, fu$lity has to be truly FELT, not just known

The Singular Work of Sadness • RELIEF from the emo'onal pressure of stuck & stale frustra'on • emo'onal RESET and RENEWAL as frustra'on is RESOLVED • emo'onal REST from fu'le work, rendering discipline eﬀec've and enabling healing and leYng go

• RECOVERY of the capacity for fulﬁllment and happiness as well as the spontaneous realiza'on of poten'al • develops RESILIENCE as strength results from facing and feeling fu'lity • RESTORES hope and perspec've

drives the transforming process of ADAPTATION

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Attachment’s Emergency First Aid Team

OUR MOTTO - “We promise to get emo.onal when holes appear in the fabric of your togetherness” “We also promise to hang around un.l fu.lity is felt”

The Work & Wisdom of Frustration • how Nature ensures our ongoing personal EVOLUTION, developing us as agents of change and transforming us when that change is not possible, thus con'nually moving us towards a more sa'sfying state of being • how Nature takes CARE of us, regardless of the situa'on or circumstances we are born to, and regardless of what happens along the way • could be considered the core work of THERAPY, that is, to facilitate the work of frustra'on

moved to make things WORK

frustration or to REST from fu'le endeavours and be CHANGED instead

frustration A STORY OF ALTERNATE OUTCOMES

Frustra'on Traﬃc Circle - Gordon Neufeld

hitting & fighting fits & tantrums

Jack Hirose Seminars - Fall, 2023

acting mean & rude hostility attacking gestures foul moods & cutting words

selfattack

self-deprecation irritability & impatience

suicidal ideation violent fantasies vicarious attacks

putdowns & shaming biting, throwing, screaming

ignoring, shunning, ostracizing

sarcasm & insults

ERUPTIONS OF FRUSTRATION-FUELED ATTACKING ENERGY ie, the face of frustra'on when thwarted in its purposes

- a messy construct that interferes with insight as to its varied emo'onal roots

- if frustra'on-fueled, results from aRacking impulses that have been displaced to the self

- most of what is referred to as - self-aRack can take many forms – self-harm (ie, burning, cuYng, self-derision, self-hatred, selfhair-pulling) is rooted in being depreca'on, self-nega'ng, selfso defended against the primal hiYng, AND also includes most emo'on of alarm that engaging suicidal idea'on and impulses in alarming behaviour evokes an adrenalin rush without any - some other mo'va'ons for suicide are PURSUIT (eg, to join a loved one, corresponding sense of increase one’s status), ALARM (prevulnerability. This kind of selfharm can also evoke the body’s empt a terrifying scenario), or as a DEFENSE against an unbearable defenses against pain. experience The current construct of self-harm tends to eclipse and camouﬂage its varied emo8onal roots in alarm, frustra8on and pursuit

highly frustrated

frustration aNacking impulses are UNtempered

THE ANTECEDENTS OF AGGRESSION

FUTILITY is encountered but NOT FELT

A T T A C K

COMMON MISTAKE Imposing consequences to frustra8on-fueled behaviour that fuel its antecedents

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

TRAVERSING

THE TRAFFIC CIRCLE OF MODEL OF

frustration EXAMINING THE ROLES OF ... • MATURATION in influencing outcomes • ATTACHMENT, especially in the depression and displacement of aRacking impulses • FEELING in influencing outcomes • EMOTIONAL PLAY in influencing outcomes

frustration THE

MATURITY FACTOR

lacking a developed capacity to hold on when apart

frustration

lacking a rela$onship with frustra$on lacking ability to eﬀect change

THE IMMATURITY FACTOR IN AGGRESSION

lacking an opera$onal prefrontal cortex A and thus mixed T feelings

T A C K

lacking cogni$ve support for fu$lity

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Neufeld’s Five-Step Model of Emotional Maturation

reﬂec$ng

mixing

feeling

naming COMMON MISTAKE Not retrea8ng far enough developmentally in order to get at the root of the emo8onal immaturity

expressing

lacking rela$onship with frustra$on

frustration

lacking an d opera$onal an cortex prefrontal n tmixed A o thus iand en at feelings

lacking ability to eﬀect change

m ur ch at tta IMMATURITY lm a FACTOR na t of o i ot en m pm e lo t or eve p lacking d p cogni$ve support Su tfor hefu$lity THE

T T A C K

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration unable to change that which counts

develops a working prefrontal cortex THE MATURATION FACTOR IN DEPRESSION

failing to access the sadness that fu$lity should evoke

frustration expression of foul frustra$on blocked A by mixed feelings

unable to change that which counts DEPRESSION AS A TRAFFIC JAM

T T A C K

failing to access the sadness that fu$lity should evoke

frustration THE

ATTACHMENT FACTOR

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

THWARTED

PROXIMITY frustration where aNached aNacking impulses are untempered THE ATTACHMENT FACTOR IN AGGRESSION

aNempts at togetherness are fu$le

A T T A C K

access to sadness is foiled by lack of safe & comfor$ng aNachment

THWARTED

PROXIMITY frustration where aNached

A T T A C K

THE ATTACHMENT FACTOR IN DISPLACEMENT

DISPLACED to reduce the threat to working aTachments (can also be displaced to SELF, fueling suicidal impulses & idea8on)

the brain defensively DEPRESSES frustra$on for the sake of aNachment

THWARTED

PROXIMITY frustration where aNached

THE ATTACHMENT FACTOR IN DEPRESSION

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

e ms irritability eng self tantru -pun rev ds self-blame i shm hos s ent 8lit insult AGGRESSION y arcasm impa8ence fying g s n VIOLE 8 hiVn self-a s8 j h NCE ﬁg Tack u g

foul

wor

ANGER

GUILT

SHAME

judgements regarding whose fault

FRUSTRATION triggered by thwarted proximity

depression = ﬂa<ened aﬀect

The Wisdom of Depression Although inherently biased to express ourselves, when this expression threatens attachment the human brain is wisely programmed to sacrifice emotional expression for the sake of togetherness. This core internal defense results in the brain being divided against itself and comes at a great cost to energy and functioning.

frustration ng ei

d ce fa

THE b THE ANTECEDENTS n ATTACHMENT OF io t FACTOR AGGRESSION a

e uc d Re

e th

r pa se

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration THE

FEELING FACTOR

Giving the Brain the Feedback it Needs To facilitate the work of frustra.on, scenarios must end in one of two feelings - ﬂip sides of the same emo.onal coin & derived from the same La.n word ‘sate’ meaning ‘enough’ or ‘turning point’.

Today’s society lacks the wisdom to take scenarios to their emo.onal endpoints , believing instead in the‘mind’ as the answer.

anger

F RU S T R AT I O N

Accessing sadness is much easier via frustration

shame

guilt

futility

Frustra'on Traﬃc Circle - Gordon Neufeld

cannot manage frustra$on that is not FELT

Jack Hirose Seminars - Fall, 2023

frustration lack of mixed FEELINGS leaves aNacking impulses A UNtempered

without FEELINGS, aNempts to eﬀect change will be uninformed

T T A C K

FEELING AND AGGRESSION the fu$lity encountered must be FELT for frustra$on to end and adapta$on to occur

frustration a lack of feeling restricts release through symbolic expression

a lack of feeling restricts informed aNempts at change

FEELING AND DEPRESSION

a lack of feeling restricts release through sadness

frustration THE ry FEELING ua FACTOR t c

de vi o r

fe sa

gs lin e e rf o f

n sa

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration THE

PLAY

FACTOR

frustration lacking the kind of play that builds the prefrontal cortex A

lacking playful problem solving and construc$on

THE PLAY FACTOR IN AGGRESSION lacking playful aNacking and destruc$on

lacking playful access to sadness

T T A C K

frustration lack of construc$on play and ‘making things work’ play restricts release

THE PLAY FACTOR IN DEPRESSION

lack of emo$onal play that accesses sadness restricts release

lack of destruc$on play and playful aNacking restricts release

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration

c In

e as e r

c ac

s es

s nd u o gr ay l p al THE n PLAYtio o FACTOR em o t

Taking FRUSTRATION out to play

Inviting FRUSTRATION to PLAY frustra8on-fuelled energy and impulses to make things or to make things work • construc.ng and craJs • organizing and orchestra.ng • designing and engineering • developing models, sets and scenarios

frustra8on-fuelled energy and impulses to aTack or destroy • destroying & demolishing in play • play ﬁgh.ng & mock aggression • hiHng and throwing in play • kicking and screaming in play • war games, a<acking games • sword play, insult games • playful sarcasm and wit • a<acking energy in stories, art, music, dance and wri.ng

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

... pressing down on irrita'on or aggression ... trying hard not to get frustrated ... trying to make everything work ... aRemp'ng to keep posi've ... controlling one’s thoughts ... aRempts at self-control ... trying to calm down ... striving for success ... ﬁgh'ng depression

invite into play the underlying FRUSTRATION

Accessing sadness is usually easier in the play mode • renders defenses unnecessary, thus making it easier to feel

• plays directly to our emotions as in melancholy music, poetry, or a sad story

• provides something to cry about that is one step removed and thus not too much to bear

• can remove the impediments to tears such as selfconsciousness, shame, and social sanctions

• can set the stage with fantasies that reveal the futility

• contains the sadness to the parameters of play, rendering it more bearable

• shifts the locus from the HEAD to HEART, from thinking to feeling, from doing to being

• provides safe release for stuck emotion, thus making it easier to fall into our tears in the wake of intense expression

To create a story of frustration with good outcomes ... • accept that it exists and needs some space to work and to be expressed • call it by name, reframing as needed • make frustra$on the focus, not fault or resul$ng behaviour • come alongside frustra$on & its work • support outcomes that are incompa$ble with aggression, depression & suicide ... cultivate a healthy relationship with frustration

CBT Strategies for Evidence-Based Care: Nothin’ But the Skills!

Jeff Riggenb ch, PhD clinic ltoolboxset.com

CBT Strategies for Evidence-Based Care: Origins of Model

• Developed by Dr. A ron Beck, University of Pennsylv ni

• B sed on principle th t thoughts in luence feelings

CBT Strategies for Evidence-Based Care: The Cognitive Model

Events

Thoughts

Feelings

Actions

Results

CBT Strategies for Evidence-Based Care: The Cognitive Model

Events

Thoughts

Feelings

Actions

Results

CBT Strategies for Evidence-Based Care: Levels of Cognition

Core Beliefs

CBT Strategies for Evidence-Based Care: Areas of Core Beliefs

• Beliefs bout self • Beliefs bout others

• Beliefs bout the world

CBT Strategies for Evidence-Based Care: Beliefs About Self

• I m f ilure • I m worthless • I m unlov ble • I m defective • I m helpless • I m burden

CBT Strategies for Evidence-Based Care: Beliefs About Others

• Others re kind, Competent • Others re me n/judgment l/critic l • Others re unreli ble • Others re untrustworthy • Others re self-centered

CBT Strategies for Evidence-Based Care: Beliefs About the World

• The world is exciting! • The world is boring • The world is me ningless • The world is sc ry • The world is evil

CBT Strategies for Evidence-Based Care: CBT tools and techniques

1. Environment l Interventions 2. Beh vior l Interventions 3. Cognitive Interventions 4. Ph rm cologic l Interventions

CBT Strategies for Evidence-Based Care: Cognitive Interventions

1. Mindfulness 2. Distr ction 3. Cognitive Restructuring

CBT Strategies for Evidence-Based Care: Distraction Techniques

1. Take a hot bath 2. Paint 3. Go for a walk 4. Play a game on my phone 5. Go to a club 6. Stretching exercises 7. Practice Karate/Martial arts 8. Lift weights 9. Play with yarn/stressball 10. Call a friend

CBT Strategies for Evidence-Based Care: Cognitive Restructuring

1. Identifying nd L beling Distortions

Identifying and Labelling Cognitive Distortions

1. Rationalization. In an attempt to protect yourself from hurt feelings, you create excuses for events in life that don’t go your way or for poor choices you

make. We might call these permission-giving statements that give ourselves or someone else permission to do something that is in some way unhealthy.

2. Overgeneralization. You categorize different people, places, and entities based on your own experiences with each particular thing. For example, if you

have been treated poorly by men in the past, “all men are mean,” or if your first wife cheated on you, “all women are unfaithful.” By overgeneralizing, you miss out on experiences that don’t fit your particular stereotype. This is the distortion on which all of those “isms” (e.g., racism, sexism) are based. 3. All-or-nothing thinking. This refers to a tendency to see things in black and white categories with

no consideration for gray. You see yourself, others, and often the whole world in only positive or negative extremes rather than considering that each may instead have both positive and negative aspects. For example, if your performance falls short of perfect, you see yourself as a total failure. If you catch yourself using extreme language (best ever, worst, love, hate, always, never), this is a red flag that you may be engaging in all-or-nothing thinking. Extreme thinking leads to intense feelings and an inability to see a “middle ground” perspective or feel proportionate moods.

CBT Strategies for Evidence-Based Care: Cognitive Distortions

4. Discounting the positive. You reject positive experiences by insisting that they “don’t count” for some reason or another. In this way,

you can maintain a negative belief that is contradicted by your everyday experiences. The terms mental filter and selective abstraction basically describe the same process. 5. Fortune telling. You anticipate that things will turn out badly and feel convinced that your prediction is already an established fact based on your experiences from the past. Predicting a negative outcome before any outcome occurs leads to anxiety. 6. Mind reading. Rather than predicting future events, engaging in this distortion involves predicting that you know what someone else is thinking when in reality you don’t. This distortion commonly occurs in communication problems between romantic partners.

CBT Strategies for Evidence-Based Care: Cognitive Distortions

8. Emotional reasoning. You assume that your negative feelings reflect the way things really are. “I feel it, therefore it must be true.” 9. Magnification. You exaggerate the importance of things, blowing them way out of proportion. Often, this takes the form of fortune telling and/or mind reading to an extreme. This way of thinking may also be referred to as catastrophizing or awfulizing. 10. Personalization. You see yourself as the cause of some external negative event for which, in fact, you were not primarily responsible. You make something about you that is not about you and get your feelings hurt.

CBT Strategies for Evidence-Based Care: Cognitive Restructuring– Identifying ATs

• Pt l ngu ge • “Wh t w s going through your mind?” • Thought Logs • Journ ling

CBT Strategies for Evidence-Based Care: Cognitive Restructuring - Eliciting Beliefs

• Downw rd Arrow • Themes in Thought Logs • Heightened Affect • Belief Questionn ire

CBT Strategies for Evidence-Based Care:

Rational Responding - Dealing with Your “Internal Roommate”

CBT Strategies for Evidence-Based Care:

• Is It Rational? • Are there any exceptions? • What is the likelihood? • Reassigning blame • How important is it? Continuums • • If I act on these thoughts what could happen? • What is the evidence this thought is true? • Smile? • Is it helpful? • Acceptance (if cannot change) • Are there any alternative explanations? • Am I blowing it out of proportion? • Perspective-taking? Comparisons?

CBT Strategies for Evidence-Based Care:

Skills for Treating Depression

CBT Strategies for Evidence-Based Care: Behavioral Activation

• Activity Monitoring • Activity Scheduling

CBT Strategies for Evidence-Based Care: Life Areas Associated with Depression

1.Mastery 2. Pleasure 3. Meaning

CBT Strategies for Evidence-Based Care:

Skills for Treating Depression - Self Care

12345

CBT Strategies for Evidence-Based Care: Relationship Work 0% 25% 50%

Intimacy = “Into - Me - See”

75% 100%

CBT Strategies for Evidence-Based Care: Skills for Treating Depression: Gratitude

• Family • Pets • Friends • Entertainment • Housing • Kind Strangers • Financial Provision • Shoes • Senses • Time to be on earth • Teachers • Employment • God • Good Food • Nature • Laughter • Sun & Moon • Physical Health

CBT Strategies for Evidence-Based Care: Positive Psychology

CBT Strategies for Evidence-Based Care: Skills for Treating Depression - Rainy Day Coping Narrative

“Just because I can’t see it now doesn’t mean it isn’t coming”

CBT Strategies for Evidence-Based Care: Strategies for Treating Depression - Negative Cognitive Triad

• Self • Others • World/Future

CBT Strategies for Evidence-Based Care: Skills for Treating Depression - Belief Modi ication Protocol

Identify Maladaptive Belief Identify Alternate Adaptive Belief Rate Believability Interventions Rate Believability at Regular Intervals

1. 2. 3. 4. 5.

CBT Strategies for Evidence-Based Care: Belief Modi ication Protocol

CBT Strategies for Evidence-Based Care: Strategies for Treating Depression: Data Logs

CBT Strategies for Evidence-Based Care:

Anxiety = Risk/ Resources

Increased Awareness of Resources Increase Resources More Realistic Appraisal of the Risk

CBT Strategies for Evidence-Based Care:

Skills for Treating Phobias

• In-Vivo • Hier rchies • Beh vior l Experiments

CBT Strategies for Evidence-Based Care: Cognitive Behavioral Therapy: Behavioral Experiments

1) Identify Assumption w/ speci ic predicted Outcome 2) Coll bor tively ID t sk th t will test ssumption 3) Experiment must h ve cle r be ring on v lidity 4) Review Findings

https://www.youtube.com/w tch?v=jRFfDps3_6M

CBT Strategies for Evidence-Based Care: Strategies for Treating Panic Disorder

• Trigger is nxiety vs environment l • Restructure Misinterpret tion of sx • Interoceptive Str tegies

Empirically supported protocol: Clark, Barlow

CBT Strategies for Evidence-Based Care: Strategies for Social Anxiety

• Trigger is lw ys people • Approv l-Seeking Schem Work • Ch llenging People Ple sing Cognitions • Continuums

I—————————————————————————————————I My Wife Neighbor’s Dog

• Polling Exercises

CBT Strategies for Evidence-Based Care: Skills for Treating Anxiety - Schema Based Journaling

CBT Strategies for Evidence-Based Care: Anger Management

CBT Strategies for Evidence-Based Care: Skills for Treating Anger and Impulse Control

• Identi cation of Triggers • Identi cation of Target Behaviors • Identify Bodily Sensations • Identi cation of Emotions • Challenging “Hot” Cognitions • Coping Statements • Role Plays • Letter Writing • Values Clari cation • Schema/Forgiveness Work • Pros and Cons

CBT Strategies for Evidence-Based Care: Skills for Treating Anger and Impulse Control

• Anger Aw reness Exercises • Ch llenge Shoulds (Pr ctice Accept nce) • Assertiveness Exercises • Express nger in s fe environment • Letter writing • Journ l of triggers nd responses • Exercise • Develop bility to emp thize with person ngry with • Count to 10 • W lk w y • Cognitive Beh vior l Ch in An lysis

_________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 0

CBT Strategies for Evidence-Based Care: Scaling Your Anger

CBT Strategies for Evidence-Based Care: Skills for Treating Anger and Impulse Control

• Challenging “Shoulds”/Acceptance

CBT Strategies for Evidence-Based Care: Cognitive Behavioural Chain Analysis

CBT Strategies for Evidence-Based Care: Skills for Anger and Impulse Control - Cue Card

CBT Strategies for Evidence-Based Care: Forgiveness-Interfering Cognitions

• • • • • •

Forgive and Forget Forgiveness = Trust If I forgive I have to like/love and stay in relationship with them If I forgive him I am letting him off the hook If I forgive I am saying what she did is ok I will not give him the satisfaction of my forgiveness

CBT Strategies for Evidence-Based Care:

Relapse Prevention • Relapse - “a recurrence of symptoms after a period of improvement”

CBT Strategies for Evidence-Based Care: Relapse Prevention: Warning Signs

• Appetite Disturb nce • Sleep Disturb nce • Esc l tion in suicid l or self-injurious thoughts • Incre sed “moodiness”/ git tion/“Stressed out” • Soci l Withdr wl • Feeling “disconnected”/P r noid

CBT Strategies for Evidence-Based Care: Relapse Prevention Road to Recovery

• Things I’m Doing Right • Vulner bilities to rel pse • Episode M n gement • F iling Forw rd • Ro d to Recovery • Restructuring Cognitions Rel ted to Loss • Booster Sessions

Relapse Prevention: How Do I Know I am Getting Better?

Questions???

Schizoid Personality Disorder Associ ted Fe tures

- Dif iculty Expressing Anger - P ssivity - Brief psychosis under stress

LET’S CONNECT! Website: clinicaltoolboxset.com Email: jeff@jeffriggenbach.com Facebook:

DrJeff Riggenbach

• Bro d, comprehensive theme or p ttern • Comprised of memories, cognitions, emotions, bodily sens tions

• Developed in childhood, el bor ted in dulthood

THANK YOU!

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

R AU S S E MA R T S and resilience Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

sense of safety

optimal functioning

role of relationship The Story of Resilience

sense of strength

Theemotional WISDOM ! tears of grieving defense futility stress of the ! vulnerable & sadness Response feelings Chapter One Stress Response impact1 Chapter of

TRAUMA

experience &

play & Theexposure hidden and playfulness nature

surprising WISDOM! of emotion of the Stress Response

fight or flight

rest and restfulness

recovery and healing

role of adaptation

neural plasticity antecedents to bouncing back vasovagal

response

The Story of Resilience Chapter One

Chapter 1

The WISDOM ! of the ! Stress Response

The hidden and surprising WISDOM! of the Stress Response

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

STRESS

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

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

mov ing

STRESs

threats to iden tity

sec rets

CHANGE

adopI

yc da

e loss of loved on

er anoth

DIVORCE

E NT US RETIREME AB

g siblin

ST LO ng i e b resi d sch enIal ool

Adversive Childhood Experiences pHysical abuse emotional neglect Mental illness of household member

Emotional abuse

physical neglect

STRESs divorce incarcerated relative

sexual abuse

substance abuse in household

mother treated violently

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

STRESs FACING SEPARATION

= experience of separa9on

SEPARATION

is thus the greatest threat

ATTACHMENT = SURVIVAL and is thus our preeminent drive

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

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

d by ... not recognize

t isola tion g ngin belo n ot

ced repla

by ...

ed loneliness nt d i sc threats . a .. to o t id ou n entity ecial tw ted n o t sp no by . n .. old o BETRAY .. ED can’t hn apart BY . O e T h w ON HELD NOT LIKED BY ... NOT

closure separa6on-triggered

PURSUIT

ALARM

FRUSTRATION

cau6on

change

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Attachment’s Emergency First Aid Team

-P

R LA

-A

UR SU IT -

- FRUSTRATION -

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

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

Fixes & Fixations separa6ontriggered

PURSUIT

ALARM

FRUSTRATION

FIGHT

FlIGHT

se on sp Re

Re 9c

EM RE OTI

Sy mp at he

e th pa ym ras Pa

sp on se

The stress response in the ‘key’ of

SP ON ON A SE L

ﬁrst response

se on sp

Re SP ON ON A SE L

Sy mp at he

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

EM RE OTI

Jack Hirose Seminars - Fall, 2023

e th pa ym ras Pa

sp on se

Stress & Resilience - Gordon Neufeld

e ez d re gue l F or aI e[u int y, F rg Fa ogg , Fo F ble e Fe if trapped or thwarted, can trigger if trapped or thwarted, can trigger

a reverse thependulum pendulum a reverseswing swing of of the

The Stress Response armours the heart

al rim ons p s ate mo9 c9v n e • a ra9o a sep

• while a 9me, INHt the same that wou IBITS FEELINGS performinld interfere with in stressfu g or funcIoning l circumst ances

STRESS RESPONSE = MORE EMOTION BUT LESS FEELING

• gives us the STRENGTH and TOUGHNESS needed to funcIon or perform in stressful or wounding circumstances (also referred to as HARDINESS) • CHANGES us instantly so that we can COPE with adversity and SURVIVE distressing circumstances • summons up all our resources so we can PERSEVERE in the face of distress and OVERCOME stressful circumstances

The Story of Resilience

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

The Resilience Response as Nature’s Answer to the Stress Response

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The Stress Response

, th al e l h ial • gives us theoSTRENGTH and na ent l a i TOUGHNESS rim ons ot pot needed to p s m funcIon or perform in 9 e of ate mo or wounding n to stressful c9v9on e ocircumstances i a (also • ra at a referred to as y liz sep el ea HARDINESS) t r u ol he • while a bs d t a t th e same re an 9me, IN • CHANGES us instantly so that we can COPE with that wouHIBITS FEELINaGiSng, ld adversity and SURVIVE performin interfere w on distressing circumstances g or func cti ith in stressfu nIoning u : lM circulm f E a stances • summons up all our resources BL tim O so we can PERSEVERE in the PR op STRESS RESPONSE = MORE face of distress and OVERCOME EMOTION BUT LESS FEELING stressful circumstances

armours the heart

Stress Response

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

Resilience Response Feelings that have been inhibited bounce back to enable opImal funcIoning and the realizaIon of full potenIal

SAFETY is required for feelings to be recovered

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

Stress Response

Resilience Response

PRIMAL SEPARATION EMOTIONS ARE ACTIVATED

Feelings that have been inhibited bounce The issue is not the back to enable opImal stress response funcIoning and the but a missing realizaIon of fullresilience potenIal

FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

response that results in the stress response working unIl return of feelings exhausted. requires SAFE SANCTUARY

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

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Attachment’s Emergency First Aid Team

OUR MOTTO - “We promise to get emo.onal when holes appear in the fabric of your togetherness” “We also promise to hang around un.l fu.lity is felt”

What is missing in the stress response?

faint or freeze

or k w c devoloves lo floolinto f

FIX

O ATI

FIX FIG

G FlI

faw fan n or cy

M AR AL FRUSTRATION

UI T

xes he ﬁ , t n e e Wh re fuIl d to a nee ch. u they LT as s E F be

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The WISDOM & WORK of Sadness

RECOVERY

REST

RESILIENCE

D OWN

BOUN

LET

CE B AC

SADNESS brings RECOVERY and turns STRESS into STRENGTH

loss of job ne’s way losing facMORTA NEGLECT e o LITY loss ng ion t d a e z i g tal ing tragedy of parent ospi n ot f sibl o rejecIh s s lo on loss of child est threats to iden pty n ABUSE ti m ty dif e f er en tn es s

a traum ed v o l isolatio un n H ENT AT REM I T E lo R DE G ne N lin ACI es F s

the nadir

Stress & Resilience - Gordon Neufeld

HELP THAT IS

Jack Hirose Seminars - Fall, 2023

HELPFUL!!

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

Strength of DEFENSE

Strength of BECOMING - meant to be characteris.c -

- meant to be situa.onal found needed strength

OVERCAME

potenIal sIll unfolding

persisted despite distress

PERSEVERED

growth force persists

came through distress seemingly ‘unscathed’

SURVIVED

heart was mended and spirits were revived

changed to withstand or cope with adversive or distressing condiIons

RESILIENT

feelings recover quickly ager Imes of stress

ADAPTIVE

transformed from inside out by adversity

can funcIon or perform in highly stressful or wounding circumstances

HARDY

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

Strength of DEFENSE

Strength of BECOMING - meant to be characteris.c potenIal sIll unfolding

persisted despite distress

PERSEVERED

growth force persists

came through distress seemingly ‘unscathed’

SURVIVED

heart was mended and spirits were revived

changed to withstand or cope with adversive or distressing condiIons

RESILIENT

feelings recover quickly ager Imes of stress

ADAPTIVE

transformed from inside out by adversity

HARDY

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

fee

en de r

a ro m

f of

g lin

su lts f

m ro

can funcIon or perform in highly stressful or wounding circumstances

f lts su

lin g

found needed strength

OVERCAME

of t

- meant to be situa.onal -

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The Story of Resilience

The WISDOM ! of the ! Chapter Three Stress Response

Chapter 1

The Truth about Trauma

The truth about trauma is that is NOT in the nature of an event, no maVer how distressing the event may be. Trauma is not what happens TO us, but what fails to happen IN us as a response.

Stress Response

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

Resilience Response Feelings that have been inhibited bounce back to enable opImal funcIoning and the realizaIon of full potenIal

SAFETY is required for feelings to be recovered

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

Stress & Resilience - Gordon Neufeld

Resilience Response

Stress Response becomes PRIMAL SEPARATION EMOTIONS ARE ACTIVATED FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

Jack Hirose Seminars - Fall, 2023

Feelings that have been inhibited bounce back to enable opImal funcIoning and the Whenoffeelings realizaIon full potenIal

fail to bounce back, an acute stress response turns into TRAUMA return of feelings SAFE Traumarequires = stuck stress response SANCTUARY

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

a stuck stress response

TRAUMA a missing resilience response

an emo6onal emergency response that has failed to come to an end

SIGNS OF POST TRAUMATIC STRESS SYNDROME

in l e fe

ess l IMPULSIVENESS ut b ion FRUSTRATION ALARM t mo e re o m PURSUIT

- elevated startle response - ﬂashbacks and nightmares - avoidance of whatever alarms - intrusive thoughts & memories - unable to focus and concentrate - hyper-arousal and hyper-vigilence

- irritability and impaIence

- erupIons of aVacking energy

- self-aVack and suicidal impulses

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

SIGNS OF UNRESOLVED & RESIDUAL PRIMAL EMOTION

lin e e f

- clutching, clinging, possessing, hoarding, acquiring, impressing, pleasing, etc - fragmented fixes & fixaIons with pursuit as the theme – winning, placing, hunIng, chasing, aVracIng, demanding, reducing, seeking, enhancing, etc - preoccupaIons with altering - preoccupaIons with concealing self in pursuit of belonging, of belonging, PURSUIT oneself in pursuit love or significance love or significance

ess l ut b ion FRUSTRATION ALARM t mo e re o m

- ANXIETY - irraIonal obsessions - irraIonal avoidance - anxiety reducing behaviour - an aVracIon to what alarms - inability to stay out of trouble - recklessness and carelessness - aVenIon deﬁcits around alarm - chronic agitaIon and restlessness

- ﬁts & tantrums - hidng and ﬁghIng - obsessions with change - aggression and violence - rudeness and meanness - irritability and impaIence - erupIons of aVacking energy - self-aVack and suicidal impulses

Signs of a Stuck Stress Response UNRESOLVED alarm, frustraIon & pursuit

Missing the VITAL SIGNS of well-being

RED FLAGS for lost feeling

ful nes

s lne

vital signs of well-being

pl ay

- rest is the state from which all growth and recovery happens

stfu re

- the play mode is about opImizing and so is only acIvated when the preeminent aVachment drive is at rest

Missing the ‘Vital Signs’ of Well-Being

‘feelingfulness’

Feelings are ‘feedback’ which, despite their role in the unfolding of potenIal, are somewhat luxurious & ‘advanced’. Given how readily they are sacriﬁced by a distressed brain, they are a key indicator of emoIonal health & well-being.

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Feelings more likely to be defensively inhibited feelings of MISSING (longing, loss, empIness, loneliness, lack of invitaIon)

feeling RESPONSIBLE (sorry, remorseful, guilty about, bad about, responsible for)

feelings of CARING (caring for, caring about, love, compassion)

feelings of (fulﬁlled) DEPENDENCE (needy, vulnerable, cared for, saIated by, trusIng in)

feelings of FUTILITY (sadness, disappointment, grief, melancholy, sorrow)

feelings of ALARM (unsafe, nervous, apprehensive, cauIous, concerned, careful)

As a result ...

feeling CONFLICTED

RED FLAGS for LOST FEELING NO RECOVERY of lost feelings over Ime FUTILITY is not felt (the ‘canary’ of emoIonal distress) a proneness to BOREDOM

What BOREDOM is about

When the ‘holes’ in togetherness are NOT suﬃciently FELT, it is experienced as BOREDOM.

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Boredom-a natural barometer for deﬁcits of feeling - can’t feel the true nature or shape of the hole that exists within -

ac9v ity

food nt me n i rta

s9m

ula 9o n

al s git it di rsu pu

te en delin quen cy

ns scree

videog

ames

EARLY SIGNS OF A STUCK STRESS RESPONSE no longer talks about what distresses or hurt feelings no longer feels unsafe or alarmed no longer reads rejec9on or feels its s9ng no longer given to sadness and disappointment no longer feels as needy, empty, lonely or dependent no longer is as visibly aﬀected by loss and lack be^er able to func9on or perform under duress

RED FLAGS for LOST FEELING NO RECOVERY of lost feelings over Ime FUTILITY is not felt (the ‘canary’ of emoIonal distress) a proneness to BOREDOM ADDITIONAL RED FLAGS a diminished sensorium (especially pain & bladder pressure for youngsters and even youth) a urgent and persistent flight from feeling flaVened affect (per ‘classical’ definiIon of depression)

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The Story of Resilience

The WISDOM ! of the ! Chapter Four Stress Response

Chapter 1

How to Resuscitate the Resilience Response

Stress Response

Triggers Primal Separa9on Emo9ons FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

Resilience Response Feelings that have been inhibited bounce back to enable opImal funcIoning and the realizaIon of full potenIal

Provide SAFE SANCTUARY for FEELING

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

SAFETY It is NOT the existence of SAFETY that is required for feelings to return but rather the experience of safety that is conducive to feeling.

TWO SAFE SANCTUARIES for FEELING • SAFE RELATIONSHIP - when CLOSE to a person ATTACHED to in a trusIng DEPENDENT mode • when in the PLAY MODE and in par9cular when emo9ons are at play

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Where the helper can be ANYONE but preferably a caring adult to whom the child or adult is a^ached or will a^ach

helper

Resuscitating the Resilience Response - applying rela9onal and emo9onal ﬁrst-aid -

P HI NS

O TI LA

- parent - grandparent - rela9ve - teacher - coach - expert - counsellor - therapist - caregiver - case worker - volunteer

- helping the troubled OR helping in troubled 9mes helping the traumatized to get unstuck

Relational First Aid & Treatment • convey a strong caring ALPHA PRESENCE

• BRIDGE separaIons with other forms of connecIon • BRIDGE troubling symptoms with connecIon

• COLLECT to engage and invite dependence • COME ALONGSIDE emoIonal experience

RELATIONSHIP

• support EXISTING ATTACHMENTS with caring adults

• NURTURE (including food) in the context of connecIon

• matchmake to embed in CASCADING CARE and shielding aVachments

• ritualize some SAFE SPACES for feelings to bounce back

Through the other’s attachment to us, we can BE their ANSWER even when there are no answers: • BE their HOME

• BE their place of REST • BE their sanctuary of SAFETY • BE their SHIELD in a wounding world • BE their REASON for holding on The answer is in BEING - not in DOING or SAYING or KNOWING the right things – when empowered by the other’s attachment to us.

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Employing PLAY as emotional first aid ...

PLAY

l rea

PLAY

for

NO T

T NO

wo rk

as well as for ongoing recovery & healing

expressive

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Harness the Healing Power of Play • to LIGHTEN the emoIonal load

• to safely engage and DISTRACT in alarming situaIons

• to aid the RECOVERY of feelings so that the stress response does not get stuck

• to give the brain a chance to REST and RECOVER PLAY • to provide for SAFE EXPRESSION of primal emoIon

• to set the stage to access healing SADNESS when emoIonally ready

When drawing the child into play, we are transferring the child into the arms of NATURE so it can gently and wisely take care of the child

Emo9ons are easier to feel when one step removed from real life

Emo9ons are not at work, so the inhibi9on of feelings is reversed Play is safe so feelings won’t get hurt

Words or their lack, do not get in the way

Emo9ons are freer to move and so more likely to be felt and iden9ﬁed

Feelings of fu9lity are much easier to access

Emotional playgrounds help in the recovery of feelings

Suggestions for Harnessing Play • engage in play by giving play signals, like a bit of silliness, singing, wearing a playful cape • playfully engage in games, puzzles, stories, music, movement, drama, theatre, etc • provide materials to draw, paint, construct, make crags, make music, priming the acIvity where necessary

• take turns telling made-up stories, so their emoIons can drive something other than nightmares

PLAY

• sing or hum lullabytype songs if possible, to harness their emoIonal and connecIve power

• engage in playful connecIon, providing brief experiences of contact and togetherness that are able to disarm

• engage in the cultural play, ie, the dances, music, art of their culture of origin

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

... in our pursuit of happiness PRESS PAUSE

... in avoiding negaIve thoughts ... in aVempIng not to be upset ... in trying to stay in perspecIve ... in aVempIng to stay opImisIc ... in trying to cheer each other up ... in pudng limits on grief and sorrow ... in denying that the glass is half empty ... in trying to change the Eeyores into Tiggers

into the SADNESS whose task it is to facilitate needed endings, strengthen as required, and deliver us back to what happiness exists

S T R E P O T E N T I A L G T H

UND ING

g 9n len S

S re un TRE S

trag e

unb sepaearable ra9o n

sadness

ty rtain unce

feelings

sing distresstances circum loss & lack

t toghreate eth ne ern d ess M

ALAR

chaos

recover the resilience response

helper

Resuscitating the Resilience Response

L RE

P HI NS O I