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

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Self Care for Leaders & Health Professionals

The following principles of self-care will protect support leaders from Compassion Fatigue. Consider the follow ing 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

        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 self confidence)    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

 Empathetic communication  Talk to kids about a “beautiful day”  Talk to kids about good and evil  Talk about the triumph of goodness over evil  Evil cannot be explained  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

 Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions  Recurrent distressing dreams of the event  Acting or feeling as though the traumatic event were recurring  Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event  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

       Efforts to avoid thoughts, feelings or conversations associated with the trauma Efforts to avoid activities, places or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (e.g. unable to have loving feelings) 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

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A pervasive sense of “fear” (most days)

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A vague sense of dread (most days)

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Jumpy at work (at times)

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Difficulty concentrating at her job

Martha’s Diagnosis & Treatment Plan PTSD Case Study

 Initial Interview Martha discloses that she was robbed in a supermarket parking lot 2 years ago  As she begins to describe details of the mugging, she becomes extremely agitated, starts to shake, and has difficulty talking   This sort of thing occurs several times a day (usually when she is at home)  Martha’s breathing becomes very rapid and she begins to hyperventilate 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 co workers (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

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Evaluation of Martha Part 1

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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 ◊ Generalized Anxiety Disorder ◊ Acute Stress Disorder ◊ Obsessive-Compulsive Disorder ◊ Agoraphobia ◊ Specific Phobia ◊ Social Phobia

Evaluation of Martha

Martha’s Treatment Plan

Behavioral Definitions 1.

2.

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 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 self injurious 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 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 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