Transcript Healing Trauma With Tenderness

Healing Trauma
With Tenderness
Dr. Hannibal Silver, LPC
Psychological Stages of
Response to Disaster and
terror attacks
 Heroic community role - Time: at impact
 Magic healing - Time: 3 to 6 months after
 Disillusionment - Time: 1-2 years after
 Acceptance / redirection - Time: 2 to 3 years
Self Care for Leaders &
Health Professionals
The following principles of self-care will protect support
leaders from Compassion Fatigue. Consider the following facts.
 A disaster/ Terror attacks creates demands
beyond normal community or individual resources.
 A disaster may generate a cluster of conflicting
responses, such as guilt, anger, gratitude,
depression, anxiety, and inconsolable grief. These
conflicting emotions need processing or will
create emotional fragmentation.
 Physical symptoms may include: fatigue, headaches,
nausea, muscle pain, dizziness.
 Cognitive symptoms include: problems
concentrating, problems making decisions,
disoriented thinking.
Self Care for Leaders &
Health Professionals
 Behavioral Symptoms include: insomnia; crying
easily; such addictions as nicotine, caffeine, and
alcohol; and obsessive behaviors including sexual
acting out and addictions.
 Facing a tragedy intensifies and magnifies
preexistent bleeding wounds conditions.
 Understanding personal limits and appropriate role
is important.(love within limits)
 Monitor your own reactions to other’s pain.
 Group support and individual counseling may be
needed. emotional emergency resources are limited.
Preventing Compassion
Fatigue
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Set healthy limits for your family and friends:
Learn how to say NO
Find rewarding professional activities
Avoiding exposure to chaotic or stressful situations or
relationships which trigger unregulated emotions
Balanced cycle of rest, work, spiritual and
recreational activities.
Goodness is stronger than evil
Eating good balanced meals
Develop realistic expectations about the rewards and
hazards of helping people
Share responsibilities with others
Points to Consider in
Grief Recovery
 Unresolved grief later surfaces as psychological
disorders, impulsive / Compulsive behavior, and
addictions
 Grief recovery requires intentional work
 “We grieve alone but we heal in community” (Dr. Ed
Creagan)
 Witnessing an attack (TV viewing included) may
result in Post Traumatic Stress Disorder
.
*Psychologists predict that 25% of the population is
expected to develop PTSD in the wake of the World
Trade Center, Iraqi, Madrid, and London attacks
Self - Defeating
Strategies
 Letting Fate define your life
 Letting Fear run your life
 Letting the past rule your life
 Letting others guide your life
ABCs of Crisis
Intervention
Warning: Crisis intervention can be intrusive and
harmful if not properly done.
 Approach
 Basic Agenda
 Coping Skills
 Coping Suggestions
ABCs of Crisis
Intervention
Approach
 Time for description, not for prescription
 Time for understanding, not for advice
 Time for personalized assessment, not for
generalized care
 Time for empowering affirmation, not for
conveying pity
ABCs of Crisis
Intervention
Basic Agenda
 Listen to the personal stories of tsunami victims
 Understand their religious world view
 Identity most pressing needs and problems
 Review and clarify the trauma experience
 Focus on the human ability to re-bounce and
renewal
ABCs of Crisis
Intervention
Coping Skills
 Cultivate a new plan for living within the
new scenario.
 Develop redemptive responses to evil
 Reaffirm the goodness of a new life
 Explore translating pain into words
 Silence can be deadly
ABCs of Crisis
Intervention
Coping Suggestions
Part 1
 Give yourself permission and time to grieve
 Focus on your neglected dreams and goals.
 Redefine your priorities, and focus your energy
and resources on those priorities
 Ask for support and help from mosque synagogue - church, or other community
resources.
 Learn how to develop M*A*S*H caring
communities (contact GCC counselors about
that)
ABCs of Crisis
Intervention
Coping Suggestions
Part 2
 Eat healthy meals, and exercise
 Set small, realistic goals to help tackle obstacles. For
example, reestablish daily routines for yourself and
for your friends
 Get enough rest to increase your reserve strength
 Acknowledge unresolved issues, and use the hurt and
pain as motivators to make necessary changes to heal
ABCs of Crisis
Intervention
Coping Suggestions
Part 3
 Continue to educate yourself and your
friends and relatives about normal
reactions to disaster
 Talk to your children. Be supportive. Set an
example by expressing your feelings and by
showing problem solving skills in dealing
with emotional troubles
 Remember that you are not alone
Healing Strategies
 Realize your trauma (avoid denial and fake selfconfidence)
 Listen to your heart, and talk to it.
 Translate your pain into words
 Know, respect, and express your limits. (Help
people understand you)
 Use pain as a gift - develop growth strategies
 Face the here and now through a wisdom
perspective
Wisdom Perspective
 The True Self is the combination of one’s thoughts
and emotions
 Thoughts and emotions are not a reliable source of
wisdom
 Thoughts and emotions cannot be ignored
 Mental Health is the harmonious integration of
thoughts, emotions according each person original
design.
Strategies of Flight
 Victimization (Flight from Responsibility)
 Anger (Flight from compassion)
 Pride (Flight from being Vulnerable)
 Addiction (Flight from Pain)
 Dissociation (Flight from Power)
 Self-Pity (Flight from Joy)
 Self-Absorption (Flight from Freedom)
Family Coping Strategies
Part 1
 Talk about the event
 Encourage group or community members to
describe their emotional pictures of the disaster
 Facilitate interaction and a supportive
environment
 Avoid blaming or rescuing god
 Share how the disaster has changed your views of
life, meaning and priorities
Coping Strategies
Part 2
 Explore how tragedy reveals human endurance
and solidarity
 Allow individual healing to take place
 Express appropriate physical expression of care
 Silence is gold
 Express your sorrow
 Respect space for private grief
 Accept the unfairness of life
Helping Kids to Cope
Part 1
 Explore how tragedy reveals human strength and
companionship
 Allow individual recovery to take place
 Express appropriate physical touch
 Avoid explaining suffering
 Express your sorrow
 Respect space for private grief
 Accept the unfairness of life
Helping Kids to Cope
Part 1
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Empathetic communication
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Talk to kids about a “beautiful day”
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Talk to kids about good and evil
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Talk about the triumph of goodness over
evil
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Evil cannot be explained
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Bono: people without works of love are
fiction
Helping Kids to Cope
Part 2
 Spend extra bedtime with your kids
 Listen to them
 Pray with them
 Reassure them of your love
 Bless them
 Celebrate their lives
Communication Strategies
with Kids
 Toddlers - Avoid creating an environment of sadness
around them
 Preschoolers - Respond according to their desire for
information
 School age - Discuss their concerns and questions
APA Recommendations
Part 1
 Spend more time with children and let them be more
dependent on you during the months following the
trauma. Allow your child to cling to you more than
usual. Physical affection comforts children who’ve
experienced trauma.
 Provide play experiences to help relieve tension.
Younger children in particular may find it easier to
share their ideas and feelings about the event through
non-verbal activities such as drawing.
APA Recommendations
Part 2
 Encourage older children to speak with you, and with
one another, about their thoughts and feelings. This
helps reduce their confusion and anxiety related to the
trauma. Reassure them repeatedly that you care about
them and that you understand their fears and concerns.
 Keep regular schedules for activities such as eating,
playing and going to bed to help restore a sense of
security and normalcy
APA Recommendations
When to Seek Professional Help
 Unusual Separation Anxiety
 Unreasonable fear and morbidity
 Sleep Disorders
 Loss of Concentration
 Behavioral Problems
 Isolation from friends and enjoyable
activities
 Physical Symptoms
Post-Traumatic Stress
Disorder
Post-Traumatic Stress Disorder is a debilitating
condition that follows a terrifying event. Often
people with PTSD have persistent, frightening
flashbacks, thoughts and memories of their ordeal,
and they feel emotionally numb.
Post-Traumatic Stress Disorder
 People with PTSD repeatedly re-live their trauma in the
form of nightmares and disturbing day-time
recollections
 They may also experience sleep problems, depression,
feelings of detachment or numbness, and they may be
easily startled
 They may lose interest in things they once enjoyed, and
they might have trouble feeling affectionate
Post-Traumatic Stress Disorder
 They may feel irritable, more aggressive or even
violent
 Seeing things that remind them of the incident may be
very distressing which could lead them to avoid
places or situations that bring back those memories
 Anniversaries of the event are often extremely
difficult
Specific Symptoms of PTSD
Part 1
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Recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions
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Recurrent distressing dreams of the event
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Acting or feeling as though the traumatic event were
recurring
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Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event
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Physiological reactivity upon exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event
Specific Symptoms of PTSD
Part 2
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Efforts to avoid thoughts, feelings or conversations
associated with the trauma
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Efforts to avoid activities, places or people that arouse
recollections of the trauma
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Inability to recall an important aspect of the trauma
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Markedly diminished interest or participation in significant
activities
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Feeling of detachment or estrangement from others
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Restricted range of affect (e.g. unable to have loving
feelings)
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Sense of a foreshortened future (e.g. does not expect to
have a career, marriage, children, or a normal life span)
Specific Symptoms of PTSD
Part 3
 Difficulty falling or staying asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hyper-vigilance
 Exaggerated startle response
 Fear for our own safety and future
Martha’s Diagnosis & Treatment
Plan
PTSD Case Study
Initial Intake
 Martha is a 58-year-old married woman
 She has 3adult children and 2
grandchildren
 Due to Martha’s condition, she and her
husband are only marginally involved in
the church (in the past, she was fairly
independent and was involved in a number
of religious activities)
Martha’s Diagnosis & Treatment
Plan
PTSD Case Study
Symptoms
 A pervasive sense of “fear” (most days)
 A vague sense of dread (most days)
 Jumpy at work (at times)
 Difficulty concentrating at her job
Martha’s Diagnosis & Treatment
Plan
PTSD Case Study
Initial Interview
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Martha discloses that she was robbed in a supermarket parking
lot 2 years ago
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As she begins to describe details of the mugging, she becomes
extremely agitated, starts to shake, and has difficulty talking

Martha’s breathing becomes very rapid and she begins to
hyperventilate
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This sort of thing occurs several times a day (usually when she is
at home)
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At times she feels like she is going crazy (she can’t understand
why this occurs)
Martha’s Diagnosis & Treatment
Plan
PTSD Case Study
Description of Trauma

One day, late afternoon, she decided to purchase a few things at
the grocery store. As she was in the parking lot a car drove close
to her and a man leaned out and grabbed her purse, which she was
carrying over her shoulder. The car then continued to drive off;
however, Martha held on to her purse and was dragged several
hundred yards before she finally let go

In addition to cuts and bruises from being dragged, Martha
suffered severe injuries to her arm and had to have surgery. When
she came for counseling, she was still undergoing physical
therapy
Martha’s Diagnosis & Treatment
Plan
PTSD Case Study
Current Conditions

She is isolated and only interacts with her immediate family and coworkers (at her job)

Every time she was anywhere near the site of the robbery, she
began to cry uncontrollably. (She has moved to another state)

Martha is reluctant to go anywhere that is unfamiliar to her

Overall, Martha is very reluctant to drive; her husband must
driver her to any new place
Martha’s Diagnosis & Treatment
Plan
PTSD Case Study
Legal Matters
Martha has a lawsuit pending against the grocery store in
whose parking lot the robbery took place. She is claiming
the store could have provided security protection for its
customers because it is in a known crime area. According to
her lawyer, Martha is likely to receive some settlement
from her suit
Evaluation of Martha
Part 1
.
◊
There must be severe trauma. Martha’s robbery experience
with severe injuries fulfills the important feature of the
diagnosis: the stressor must be unusually traumatic
◊
The Stress must be relieved in some way. Martha’s
uncontrollable crying anywhere near the site of the
robbery, as well as her distress and physiological
symptoms in recollection of the event during the session
and at home, fulfills this second criteria
Evaluation of Martha
Part 2
3. The patient must attempt (willingly or unwillingly) to achieve
emotional distance from the stressful event. Martha was moved
to another state, she is reluctant to go anyplace with which she
is not familiar, and she is reluctant to drive unless there is an
absolute necessity to do so. Distancing can also be
accomplished by a general numbing of emotional responsiveness
(isolation from others, inability to love). Martha also meets this
criteria through isolation: she only interacts with her immediate
family, or with co-workers at her job
Evaluation of Martha
Part 3
4. PTSD patients must have symptoms of increased arousal. Martha
suffers from poor concentration, excessive fear and dread, and
recurrent panic attacks. Martha’s panic attacks have a clear
relationship to a particular stimulus (the trauma). Such attacks
are said to be cued or situationally bound. Martha’s attacks
appear to be also invariably, becomes panic-stricken when
confronted by the stimulus.
Evaluation of Martha
Differential Diagnosis
◊
Adjustment Disorder
◊
Acute Stress Disorder
◊
Obsessive-Compulsive-
Disorder
◊
Generalized Anxiety
Disorder
◊
Agoraphobia
◊
Specific Phobia
◊
Social Phobia
Evaluation of Martha
Martha’s Treatment Plan
Behavioral Definitions
1.
Exposure to a life-threatening event that caused
serious physical and psychological injury, and which
resulted in an intense emotional response of pervasive
fear and dread
2.
Intense distress when exposed to reminders of the
traumatic event, composed of physiological reactivity
when exposed to internal or external cues that
symbolize the traumatic event
Evaluation of Martha
Martha’s Treatment Plan
Behavioral Definitions
3. Lack of interest and participation in significant activities
and relationships
4. Family dynamics become more disrupted, to the point
where specific roles of family members are changed
Evaluation of Martha
Long-Term Goals
1.
Pull together and develop ways to function more
cohesively in the face of the major life event
2.
Develop and implement effective coping skills to carry
out normal responsibilities, and participate
constructively in relationships
Evaluation of Martha
Short-Term Objectives
1.
Identify the symptoms of PTSD that have caused
distress and have impaired functioning
2.
Consider referral of Martha for medical treatment
and possible medication
3.
Identify how PTSD symptoms have affected marital and
family relationships functioning at work or church,
social, and recreational life
Evaluation of Martha
Short-Term Objectives
4. Assist Martha in finding a community support system for
the development of coping skills
5. Report increased comfort and ability to talk or think
about the traumatic incident without emotional turmoil
6. Participate in conjoint and/or family therapy sessions.
Engage in group activities as a family unit to build
cohesiveness.
7. Explore the possibility of using psychological and
spiritual resources to facilitate healing and recovery
Evaluation of Martha
Counseling Interventions
1.
Ask the patient to identify how the traumatic event has
negatively affected her life
2.
Refer Martha to psychiatric evaluation, and maintain
collateral involvement with the treating professional
3.
Conduct family sessions to facilitate the expression of
family members’ feelings, and begin to discuss the
differences in perception of the event and how it has
affected each of them differently. Prompt each family
member to describe any emotional, cognitive, or
behavioral changes that have resulted from trauma
Evaluation of Martha
Counseling Interventions
4. Refer patient to group sessions where the focus is on sharing
traumatic events and their effects with other PTSD survivors
5. Apply Solution-Focused Techniques - such as the miracle
question, scaling questions/goals, attention to the
exceptions, amplifying positive changes - in order to empower
the patient in dealing with the trauma
6. Enlighten the family as to how various family groups cope
differently in the face of crisis. Explain how the pre-existing
conditions such as previous history of depression or other
emotional disorder; physical, verbal or sexual abuse; history
of anxiety; or dysfunctional family system predisposes them to
deal with such events in a particular way
The Signs of Unresolved
Trauma
1. Suicidal Ideation
2. A pattern of out-of-control and selfinjurious behavior
3. Self-destructive addictions:
a. Dual Diagnosis
b. Eating Disorders
c. Self Mutilation
d. Sexual Addictions
The Signs of Unresolved
Trauma
4. Intrusive thoughts, images feelings and nightmares
5. Flashbacks
6. Extensive comorbidity/multiple diagnoses
7. Inability to tolerate feelings or conflicts
8. Intense self-blame and feeling unworthy
9. Staying stuck in the victim or perpetrator roles
10. Disorganized attachment patterns
11. Black and white thinking and other cognitive distortions
12. Pathological dissociation
How To Assess For Trauma
1.
Have you ever experienced emotional abuse? By whom?
2.
Have you ever experienced neglect? By whom?
3.
Have you ever experienced physical abuse? By whom?
4.
Have you ever experienced sexual abuse? By whom?
5.
Do you ever have intrusive thoughts or images
regarding the (emotional, neglectful, physical, and or
sexual) experience that you previously mentioned?
6.
Do you ever experience flashbacks or feel like the
abuse is still happening?
How To Assess For Trauma
7. Are your presenting symptoms (suicidal ideation, homicidal
ideation, inability to function, self injurious behaviors, or
addictions) in any way associated with your past
experience?
8. Do you ever lose time?
9. Do you feel you often acting on impulses and don’t have
control over your behaviors?
10. Do you have difficulty managing feelings of anger,
sadness, shame and rage?
11. How did your family express their feelings when you were
growing up?
Evaluation of Martha
Long-Term Goals
3. Terminate the destructive behaviors that serve to
maintain escape and denial while implementing behaviors
that promote healing, acceptance, and responsible
living
4. Recall the traumatic event without becoming
overwhelmed with negative emotions
5. Re-establish healthy and appropriate family role
assignments
Evaluation of Martha
Counseling Interventions
1.
Ask the patient to identify how the traumatic event has
negatively affected her life
2.
Refer Martha to psychiatric evaluation, and maintain
collateral involvement with the treating professional
3.
Conduct family sessions to facilitate the expression of family
members’ feelings, and begin to discuss the differences in
perception of the event and how it has affected each of them
differently. Prompt each family member to describe any
emotional, cognitive, or behavioral changes that have
resulted from trauma
Evaluation of Martha
Counseling Interventions
5. Apply Solution-Focused Techniques - such as the miracle
question, scaling questions/goals, attention to the
exceptions, amplifying positive changes - in order to
empower the patient in dealing with trauma
6. Enlighten the family as to how various family groups cope
differently in the face of crisis. Explain how the preexisting conditions such as previous history of
depression or other emotional disorder; physical,
verbal or sexual abuse; history of anxiety; or
dysfunctional family system predisposes them to deal
with such events in a particular way
The Signs of Unresolved
Trauma
1.
Suicidal Ideation
2.
A pattern of out-of-control and self-injurious behavior
3.
Self-destructive addictions:
a. Dual Diagnosis
b. Eating Disorders
c. Self Mutilation
d. Sexual addictions
4. Intrusive thoughts, images, feelings and nightmares
5. Flashbacks
The Signs of Unresolved
Trauma
6. Extensive comorbidity/multiple diagnoses
7. Inability to tolerate feelings or conflicts
8. Intense self-blame and feeling unworthy
9. Staying stuck in the victim or perpetrator roles
10. Disorganized attachment patterns
11. Black and white thinking and other cognitive
distortions
12. Pathological dissociation
How to Assess for Trauma
1.
Have you ever experienced emotional abuse? By whom?
2.
Have you ever experienced neglect? By whom?
3.
Have you ever experienced physical abuse? By whom?
4.
Have you ever experienced sexual abuse? By whom?
5.
Do you ever have intrusive thoughts or images regarding
the (emotional, neglectful, physical, and or sexual)
experience that you previously mentioned?
How to Assess for Trauma
6. Do you ever experience flashbacks or feel like the abuse is still
happening?
7. Are your presenting symptoms (suicidal ideation, homicidal ideation,
inability to function, self injurious behaviors, or addictions) in any
way associated with your past experience?
8. Do you ever lose time?
9. Do you feel you often act on impulses and don’t have control over
your behaviors?
10. Do you have difficulty managing feelings of anger, sadness, shame
and rage?
11. How did your family express their feelings when you were growing
up?
Global community
counseling
Provides free online counseling for victims of natural
disasters and terror attacks and free consultation for
helping personnel
For more information visit our website
www.gccusa.org