Transcript Treatment of PTSD in Veterans: Revisiting Holistic Treatment

Presented to
IN-ARMS Annual Conference
Friday, March 6, 2015
Clyde Angel, DMin., BCC, LPC
John Sullivan, LCSW
c
 Trauma is about wounding
 The initial wounding is the trauma event
Trauma as defined by patient:
Trauma = earthquake & Flashbacks = aftershocks.
The metaphor of an earthquake is a good one because a trauma
event can shake one's very foundation. This is what prompts
some to remark, “When x happened, nothing seemed to matter
anymore.” While others say, “At my core, I’m NOT the same.”
J
Wounding occurs on many levels:
 Initial Wounding (The Trauma Event)
 Secondary Wounding
Third Level of Wounding
Fourth Level of Wounding
J
 Spirituality is the aspect of humanity that refers to the way
individuals seek and express meaning and purpose and the way they
experience their connectedness to the moment, to self, to others, to
nature, and to the significant or sacred.
 Spiritual distress arises when one of these relationships that provide
meaning is threatened or broken… the individual becomes
disconnected from their system of beliefs … there is conflict
between a person’s held values and perceived reality.
 Spiritual recovery is a journey of establishing, rethinking, and
redefining one’s sense of self and relationship to life.
c
 Signature wound is loss of trust
 Compromise of one’s core values or beliefs
 Trauma event is greater than the spiritual
formation formed prior to the traumatic
experience
 Need for Spiritual Re-Formation
c
DIS-EASE
DISTRESS
DISTRUST
UNHAPPINESS
PAIN
DANGER
FEAR/ANGER
BIOLOGICALLY
BASED NEEDS
Air – Food – Water – Shelter
BONDING
(Emotional Openness/Physical Closeness)
SYMPTOMS OF
UNHAPPINESS
SIGNS OF
HAPPINESS
Illness, Fatigue
Depression
Rigidity of Personality
Constriction, Isolation
Closed, Guarded, Wary
Anti-Social Behavior
Range of Addictions:
Drugs, Alcohol
Food, Shopping, Work
Gambling, Internet
Health, Energy
Well Being
Flexibility
Creativity
Open, Sharing
Personal
Responsibility
Capacity for Intimacy
EASE
EU-STRESS
TRUST
HAPPINESS
PLEASURE
DESIRE
LOVE
What exactly is the disorder in PTSD?
While it is true the DSM-IV lists PTSD as an anxiety
disorder, it is also a
Disorder of Recovery
J
The treatment of patients suffering from PTSD
is facilitated when they are already
successfully working a Recovery Program such
as AA or EA. As they discover there are
concepts that are interchangeable between
recovery programs many gain hope and
confidence that they can achieve further
success in recovery.
Examples
 “Stinkin’ thinkin’” (cognitive distortions)
 “½ Measures” (proper medications w/o therapy or vice versa)
 “Sick as your secrets” (denial/repression/avoidance)
J
As people make the subtle move from I FEEL TO I AM
…what had been at first a feeling becomes their identity as
they move from:
I feel Incompetent TO
I feel inferior
TO
I feel careless
TO
I feel immoral
TO
I am incompetent
I am inferior
I am careless
I am immoral
The move from I feel immoral TO I am immoral is an
indication of a 4th level of wounding……
J
When one moves from:
“I feel immoral” to “I am immoral”
….accompanied by debilitating feelings of
shame and guilt and a shattered sense of
trust….
This is a reflection of fourth-level wounding.
That is, wounding at the level of one’s essence
as in “My core is NOT the same.”
J
 In the 12-Step Recovery Model people are the most highly
invested in treatment when they “hit bottom”. This in part
explains why it is so long before many seek help with
PTSD—they eventually hit an “emotional bottom” when
various means of avoiding no longer work for them.
 “I kept pushing it down, now it is pushing back.”
 As with other recovery disorders, those suffering with
PTSD may have enablers who attempt to convince the
patient and the provider to end treatment in its early
stages as they observe the patient getting worse before
they get better.
J
A big piece of what needs to be processed relates to
certain questions that are forced to the forefront of
one’s conscience and consciousness following a
trauma.
Answering these questions is basic and fundamental to
our peace and well being which is what gives them
such urgency.
When such questions are viewed primarily as
“profound” this narrow view can actually promote
avoidance behavior.
Avoidance is the lifeblood of PTSD
 Why did this happen to me?
 What caused this trauma event?
 Was this a test from God?
 If it was a test, is there a way to pass this test?
 When is this test going to end?
 If it was a punishment, what did I do to deserve punishment?
 Why did I survive when others died? [SE variation on this question]
 If God has forgiven me and I have not, can I ever be forgiven?
 If God forgives me and I do not, does that place me above God?
c
Recovery entails:
Finding MEANING in trauma events and Discovering
ANSWERS to pressing fundamental questions related to these
events
The key to recovery via meaning and answers is
ACCEPTANCE
Answers and meanings must be those one can literally LIVE with since
“recovery” is movement from survival mode to LIVING.
One is better able to move on with life as the impact of memories becomes
less disruptive to functioning during the course of treatment.
c
Answers to fundamental questions/beliefs and
attaching meaning to events is important.
Acceptance of these answers and meanings is
Crucial.
“I saw his reflection in the wall…”
c
The only way to get BEYOND traumas is to go
THROUGH the traumas…
this is a scary proposition…
You can’t go over, under or around them…
Avoidance will not get you BEYOND them
Avoidance is the lifeblood of PTSD
J
 Anger Management vs. Anger Resolution
 Loss and Grief
 Shame, Guilt and Forgiveness (to include self)
c
When patients believe they have betrayed their own values,
morals, conscience, their essence/core or what was once
referred to as their very SOUL and that they did so because
every one of their so-called "choices“ were morally
reprehensible and emotionally devastating leaving them
feeling coerced into this self-betrayal, we as providers need
to ask ourselves:
Can our current approaches to treatment address
the gravity and depth of one’s social-psychospiritual reaction to this perceived self-betrayal?
J and C
Certainly spiritual wounding involves
“moral injury”. However, the cluster of
symptoms that make up spiritual
wounding is broader than moral injury.
c
The Shattering of Trust
Disconnection and alienation from:
Family
Friends
One’s Higher Power
SELF
Guilt Issues
Shame
Moral Injury
Unresolved grief (so many losses)
Issues related to Conscience
c
Love Knots are commonly held
beliefs that seem to be true.
However, they are not true because
they are not based on logical,
realistic thinking. Love Knots can be
very harmful to relationships.
LOVE KNOT #1:
You would know …
LOVE KNOT
UNTANGLED
If you really loved me,
you would know what I
want, and you would do
it. Since you don’t, you
obviously don’t care.
I cannot assume that
you know what I want
and need. I will ask for
what I want and not
expect you to know.
LOVE KNOT #2:
When I tell you …
LOVE KNOT
When I tell you how I
feel, you interrupt,
disagree, give advice,
judge, or dismiss my
feelings. That’s not
what I want. I stop
telling you. I distance
myself from you.
UNTANGLED
If I want you to listen to
me and to hear me
without comment, I
need to ask for that.
Advice is not helpful
when the person does
not want it. Learning
how to listen attentively
is often more important
than giving advice.
LOVE KNOT #3:
If you are in pain …
LOVE KNOT
If you are in pain, I
believe I should be able
to fix it. I don’t know
how to fix it, so I feel
inadequate. I get angry
with you for making me
feel inadequate. I
withdraw from you and
blame you for being in
pain.
UNTANGLED
When you are in pain, I
can be supportive
without believing I have
to provide a solution. I
can listen, empathize,
and acknowledge what
you say. I will respect
and honor your feelings
as well as your ability to
ask for what you want.
LOVE KNOT #4:
If I tell you …
LOVE KNOT
If I tell you what I want
and you do it, it doesn’t
count (because I had to
tell you). If you try to
guess what I want and
you don’t get it right, I
get angry.
UNTANGLED
I cannot expect you to
know what I want. Nor
can I expect you to do
anything exactly the way
I would. I can still
appreciate the gift of
whatever you do because
you believe I would like
it.
LOVE KNOT #5:
I will need you …
LOVE KNOT
UNTANGLED
If I let myself get close
to you, I will need you.
If I am too dependent
and need (love) you
too much, I will not be
able to survive without
you. I will become
weak.
I can enjoy being close to
you yet still survive on my
own if I need to. As an
adult, I am not helpless. I
can make a new life for
myself if I have to.
Meanwhile, the pleasures
of intimacy are among life’s
most fulfilling gifts.
LOVE KNOT#6:
If we don’t agree …
LOVE KNOT
If we don’t agree, one of
us must be wrong. If it’s
me, that means I am
bad, stupid, ignorant, or
inadequate. So it can’t be
me. I must prove that it’s
you so I won’t feel like a
failure.
UNTANGLED
We should be able to
disagree. We are all
unique, and
disagreements are a
natural reflection of our
uniqueness.
LOVE KNOT #7:
If I ask …
LOVE KNOT
UNTANGLED
If I ask what you are
thinking or feeling, I
believe I am intruding
(as you would tell me if
you wanted me to
know). If I don’t ask, you
believe I’m not
interested, so you never
tell me. We live as
strangers.
Confiding is the life
blood of intimacy. I need
to be able to ask for
information, and you
need to be able to
volunteer it when I don’t
ask, if we are to nurture
our relationship. It is
crucial that we speak our
truths, ask our
questions, and keep each
other informed.
Start
Here
I hope …
I realize …
What you can do
to help me is…
What I can do for
myself to untangle
this knot is…
The price you have
paid for my knot
is…
The Love Knot I
want to work on
is…
My assumption
has been…
I think I have
this
belief because
What
… I needed
in my past was
…
The price I have paid in my
life for having this knot is
…
Who can tell us what a physical allergy is like? What happens?
Intense negative & positive experiences are stored in our memory.
Positive experiences we like and want to repeat.
But negative types of memories are painful and PAIRS call these…
Emotional Allergies
We remember what we feel!
My Allergy:
(TRIGGER)
Raising your
voice in anger.
Your Allergy
(TRIGGER)
Silent
Treatment.
My Feelings:
Fear
Hurt
Anger
My Belief:
Anyone who yells at
me does not love me.
Your Feelings
Hurt
Anger
Fear
Dirty Fighting
Begins
My Behavior:
I give you the silent
treatment for yelling.
Dirty Fighting
Begins
Your Belief:
Anyone who stops
speaking to me, does
not respect me, will
leave me.
Your Behavior:
I raise my voice again
and you continue not
to speak to me.
Vulnerability:
Empathy:
Allowing another person to see the
parts of you that are scared, hurt,
sad, and lonely, etc.
Imagining what it feels like to
be in another person’s shoes
Taking a risk to share your deepest
thoughts and feelings with another
person even when you are not sure
how they will react.
Imagining what that person
thinks and feels.
So What is the Common Thread?