Download WORKSHOP ON COGNITIVE-BEHAVIOURAL PSYCHOTHERAPY

Cognitive Behavioural
Treatment of Post
Traumatic Stress Disorder
SVEIKI
Jill Schofield
Miriam Grace Granthier
Training Overview
DAY ONE: Understanding and Assessing PTSD
DAY TWO: Treatment Strategies for PTSD
DAY THREE: Treatment continued, Post Traumatic
Growth and Vicarious Traumatisation.
Post Traumatic Stress Disorder –
Introduction
• As the name implies, posttraumatic stress disorder
occurs only after (post) an extremely stressful event
(trauma).
• In the aftermath of a traumatic event, it is normal to
have feelings of detachment or emotional numbness, a
feeling of distorted or altered reality, amnesia or even
repeated reliving of the event.
• For most, these feelings will fade within the next few
weeks. For others, they become a part of life – when the
symptoms last longer than one month we begin to
conceptualise this as a disorder.
PTSD
The more severe the trauma and the longer the
person is exposed to it, the greater the likelihood of
developing PTSD. PTSD is only diagnosed after:
a) a person has been exposed to an extreme trauma;
b) symptoms develop that last at least one month;
c) the symptoms create extreme distress and
dysfunction.
It is not certain why particular reactions occur
to traumatic events, but they appear to be
influenced by at least three important variables:
1. The traumatic nature of the incident.
2. The character and personality of the
individual involved – what else is
occurring in their life at the time.
3. The preparation of the individual, and the
support given before, during and after the
event.
How does PTSD present?
There are three main categories of PTSD symptoms, and all
three must be present for the diagnosis of PTSD.
1. Cognitive - re-experiencing the trauma e.g. flashbacks,
nightmares, intrusive memories, inability to remember parts
of the trauma, dissociation.
2. Emotional and behavioural e.g. exaggerated emotional
reaction or detachment (no reaction) to triggers, feeling
different, strange or unreal, numb, losing interest and
avoiding activities or places that remind the person of the
trauma.
3. Physiological - heightened arousal state e.g. physical
reactions to triggers, difficulty sleeping, irritability, hypervigilance and exaggerated startle response.
PTSD
Re-experiencing the trauma
Re- experiencing the trauma can take the form of recurrent
images, thoughts, and dreams or "flashbacks" of the event.
Even reminders of the event can cause extreme distress, so
many people go out of their way to avoid places or events that
resemble the traumatic event in some ways.
Many
experience
increased
anxiety,
restlessness,
sleeplessness, irritability, poor concentration, hypervigilance
or an exaggerated startle response. Some are even plagued by
feelings of "survivor's guilt," because they survived when
others did not or because of certain things they may have had
to do to survive.
Guilt Variables
•
•
•
•
•
Responsibility
Justification for actions
Violation of values
Forseeable
Preventable
Other common manifestations
General sleep problems – nightmares?
Memory problems
Omen formation (I knew it was going to happen)
Domino effect – other bad things will happen
Anxiety
New fears
Self harm
Tearfulness and depression
Clinginess even adolescents
Substance/alcohol misuse
Regression – e.g. toileting and feeding
Complex PTSD
 Type one
trauma– single, simple trauma e.g. RTA
 Type two trauma– complex recurrent e.g. abuse
 Complex PTSD
Who gets PTSD?
Always
Those who had an intense reaction at the time
Those that thought they were going to die
Likely
With previous psychological problems
Closer to event
Closer to victim
With other psychological problems
With subsequent stressful life events
Without social support
Sometimes
Poorer families
PTSD - General Points
 Event Characteristics
- Assault trauma has highest incidence of PTSD.
- Man made trauma has higher incidence over
natural disaster.
- Prior exposure to trauma = vulnerability factors
Cultural Factors
• Mediates what is considered/perceived
traumatic
• Mediates victim’s response
• Mediates society’s response to victim
• May challenge professionals beliefs and
ethical codes
History of PTSD
 Soldiers Heart – 1862 American Civil War
 Railway Spine – 1866 John Erichsen
 Neurastheniac – 1869 G. Beard & E. Van Deusen
 Disordered Action of the Heart ‘Effort Syndrome’ – 1891 Boer War.
 Shell Shock – 1912 Dr Octave Laurent
 War Neurosis – 1916 World War 1
 Battle Neurosis – 1940 World War 2
 Lack of Moral Fibre – 1940 Royal Air Force
 Old Sergeant Syndrome – 1950 Korean War
 Combat Fatigue – 1961 Vietnam War
 Transient Situation Disturbance – 1968 Medical Journals
 Battleshock – 1982 Brigadier Peter Abraham
 Post-Traumatic Stress Disorder – 1979 Vietnam War Veterans
 Gulf War Syndrome – 1993 Media Reports
History of PTSD - DSM
• 1980 - PTSD included in the third edition of its
Diagnostic and Statistical Manual of Mental
Disorders (DSM-III).
• This highlighted a significant change in the
understanding of PTSD.
• It was now understood the cause was outside the
individual (i.e., a traumatic event) rather than an
inherent individual weakness (i.e., a traumatic
neurosis).
History of PTSD –
Revisions to the DSM
DSM-IV Diagnostic criteria for PTSD included a history of
exposure to a traumatic event and symptoms from each of
three symptom clusters:
• intrusive recollections,
• avoidant/numbing symptoms, and
• hyper-arousal
symptoms.
.
A fifth criterion concerned duration of symptoms
A sixth criterion stipulated that PTSD symptoms must
cause significant distress or functional impairment.
History of PTSD –
Revisions to the DSM
• DSM-5 (2013) - PTSD is no longer
categorized as an Anxiety Disorder.
• PTSD is now classified in a new category,
Trauma- and Stressor-Related Disorders, in
which the onset of every disorder has been
preceded by exposure to a traumatic or
otherwise adverse environmental event.
DSM-V Criteria: PTSD
A.
Exposure to actual or threatened death, serious injury, or sexual violence in one
(or more) of the following ways:
1.
Directly experiencing the traumatic event(s)
2.
Witnessing, in person, the event(s) as it occurred to others
3.
Learning that the traumatic event(s) occurred to a close family member or
close friend. In cases of actual or threatened death of a family member or
friend, the event(s) must have been violent or accidental.
4.
Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains; police
officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or
pictures, unless the exposure is work related.
DSM-V Criteria: PTSD
B.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic
event(s), beginning after the traumatic event(s) occurred:
1.
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
2.
Recurrent distressing dreams in which the content and/or affect of the dream are related to
the traumatic event(s).
3.
Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness of present surrounding).
4.
Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s)
5.
Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
DSM-V Criteria: PTSD
C.
Persistent avoidance of stimuli associated with the
traumatic event(s), beginning after the traumatic event(s)
occurred, as evidenced by one or both of the following:
1.
Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2.
Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that
arouse distressing memories thoughts, or feelings about or
closely associated with the traumatic event(s).
DSM-V Criteria: PTSD
D.
Negative alternations in cognitions and mood associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1.
Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative
amnesia and not to other factors such as head injury, alcohol, or drugs).
2.
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g.,
“I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous
system is permanently ruined”).
3.
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead
the individual to blame himself/herself or others.
4.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5.
Markedly diminished interest or participation in significant activities.
6.
Feelings of detachment or estrangement from others.
7.
Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings).
DSM-V Criteria: PTSD
E.
Marked alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1.
Irritable behavior and angry outbursts (with little or no provocation) typically
expressed as verbal or physical aggression toward people or objects
2.
Reckless or self-destructive behavior
3.
Hypervigilance
4.
Exaggerated startle response
5.
Problems with concentration
6.
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
DSM-V Criteria: PTSD
F.
Duration of the disturbance (Criteria B, C, D, and E) is more
than 1 month.
G. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
H. The disturbance is not attributable to physiological effects of
a substance (e.g., medication, alcohol) or another medical
condition.
Coexisting Conditions
• 60-100% of PTSD suffers
meet criteria for at least one
other Axis I disorder.,
including:
• Common Axis II Disorders
• Borderline
• Antisocial
• Major depression
• Substance abuse
• Panic disorder,
agoraphobia
• OCD
• Social Phobia
• Paranoid
• Schizoid personality
disorder
CBP understanding of
PTSD
Evolutionary Context
“…converging evidence in experimental and social psychology
and in neuro physiology suggest that much of the processing
involved in the generation of emotional experience occurs
independently of, and prior to, conscious, deliberate, cognitive
operations. Therefore working at the purely conceptual level
to effect emotional change may not produce enduring change.
Instead, therapeutic interventions are more likely to succeed
if they target the schematic processes that automatically
generate the emotional experience that underlies clients’ felt
sense of themselves. “
Gilbert, p79 2004
Bringing Explanatory models
Together
• Many practitioners use a synthesis of models to understand PTSD to
explain it to clients and to treat it.
• Mowrer 1947 2 factor theory – classical and operant conditioning
Avoidance of conditioned stimuli (trauma memory and triggers) in order
to avoid conditioned responses (fear and anxiety) leads to symptom
maintenance through negative reinforcement. Cannot explain intrusions.
• Foa and Rothbaum 1989 ‘fear network’ stimuli, responses and meaning
encoded peri traumatically. Stable and generalised - activated by anything
associated with the trauma - leads to avoidance behaviour –an information
processing model – suggests exposure to the memory in safe environment
will lead to habituation – decrease in emotional response, allow
spontaneous changes to meaning and reduce generalisation of stimuli.
Adaptation Foas Schematic model of Pathological Trauma
Memory network
Me
Say
Poor dog
Assault
Alone
Man
Park
Dog
Take sweets
Cry
Bike
Rain
Track suit
Freeeze
PTSD
symptoms
Confusion
Stupid
Danger
False associations between harmless stimuli fear network
Bringing Explanatory models
Together - Social Cognitive
• Horowitz ‘completion tendency’ 1986 – brain integrates information with
existing beliefs and will keep re-presenting data (intrusions) until
integration complete. Person will move between an integration mode and
avoidance mode, when exposure to memory and intrusions becomes too
emotionally aversive.
• Janoff Bulman 1985 constructivist model– shattering of previous world
view. – More likely in people with rigid view whether optimistic or
pessimistic (Foa 1996) – Particular beliefs may be important
predictability, controllability. Also safety, trust, power, esteem , intimacy
(Mcann and Pearlman 1990).
• Resick and Schnicke (1992) affect can include shame, anger, sadness due
to appraisal. Need to challenge faulty appraisals to lose affective
disturbance.
Shattered Worldview Janoff Bulman 1985
World is safe
Dogs keep
you safe
Nice people
have dogs
I am smart
I am ok
Adults
help you
Nothing bad ever
happens to me
Other people
are kind
I can look after myself
Bringing Explanatory models
Together 3 - Multi level Processing
• Interacting Cognitive Subsystems ICS Teasdale and Barnard
(1993) complex information multi level processing –
reliving.
• Ehlers – ‘hotspots’ 2005 - moments of greatest distress in
trauma memory/intrusions. Alternative appraisal inserted
into trauma memory either by imaginal exposure and
rescripting, reading narrative whilst thinking also of new
appraisal. If imaginal not enough then performing actions
that provide information and sensory cues incompatible
with the original meaning when focusing on the “hot spot”
(e.g., walking about if patients thought that they were
paralysed, looking at a recent photograph of themselves if
they thought they died during the traumatic event).
Ehlers & Clarke. (2000) A Cognitive Model of posttraumatic stress
disorder.
Characteristics of trauma / Sequelae
Prior Experiences/ Beliefs/ Coping
State of individual
Cognitive
Processing
during Trauma
Influences
Nature of Trauma Memory
Negative Appraisal of
Trauma and / or its Sequleae
P
E
R
S
I
S
T
E
N
T
Matching
Triggers
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Strategies Intended to Control Threat / Symptoms
Arrows indicate
following relationships:
© Think CBTthe
Ltd. [email protected]
Influences01732
= 808 626 www.thinkcbt.com Leads to =
Prevents change in =
P
T
S
D
Maintenance Cycle
Memory not processed
integrated
Memory/thought actively
suppressed and/or avoided
Intrusive memories, thoughts,
Nightmares, images
Re-experience original horror,
fear, helplessness
Integrative Cognitive Subsystems ICS
Teasdale and Barnard (1993)
– Attempts to address issues of:
• Memory
• Variability within schema over time
• Return to normal of dysfunctional thinking with no
direct cognitive intervention
• Environmental factors within aetiology
• Emotional and cognitive levels of meaning
• Using research from information processing models
of mind
The ICS Model
Limb Proprioceptive
Object Image
Visual Hue, bright
Propositional
Behavioural
Acoustic Tone
Peripheral
Emotional &
Consequences
Implicational
Articulatory Move
Morphonolexical
Speech, & language
functions
Previous learning experiences, genetic,
cultural, social and environmental
influences. The current environment
7 Front Systems
–
–
–
–
–
–
–
Limb: proprioceptive information
Peripheral: taste, touch, smell
Visual: brightness, hue and colour
Acoustic: pitch, tone and sound properties
Articulatory: movement
Object: visual imagery
Morphonological: speech meanings
2 Central Systems
– Propositional: the smallest individual units that
can convey meaning. Words as descriptors of
objects.
– Implicational: abstract thoughts and emotional
connotations attached to meanings.
ICS Definitions and Systems
PERIPHERAL SUBSYSTEMS
a) Sensory coding dimensions
(1) Acoustic (AC):
Sound frequency (pitch), timbre, intensity etc.
Subjectively, what we ‘hear in the world’.
(2) Visual (VIS):
Light wavelength (hue), brightness over visual space etc.
Subjectively, what we ‘see in the world’ as patterns of shapes and colours.
(3) Body State (BS):
Type of stimulation (e.g., cutaneous pressure, temperature, olfactory,
muscle tension), its location, intensity etc.
Subjectively, bodily sensations of pressure, pain, positions of parts of the
body, as well as tastes and smells etc.
PERIPHERAL SUBSYSTEMS
b) Effector coding dimension
(4) Articulatory (ART):
Force, target positions and timing of articulatory musculatures (e.g., place
of articulation).
Subjectively, our experience of subvocal speech output.
(5) Limb (LIM):
Force, target positions and timing of skeletal musculatures.
Subjectively, ‘mental’ physical movement.
CENTRAL SUBSYSTEMS
c) Structural coding dimensions
(6) Morphonolexical (MPL):
An abstract structural description of entities and relationships in sound
space. Dominated by speech forms, where it conveys a surface structure
description of the identity of words, their status, order and the form of
boundaries between them.
Subjectively, what we ‘hear in the head’, our mental ‘voice’.
7) Object (OBJ):
An abstract structural description of entities and relationships in visual
space, conveying the attributes and identity of structurally integrated visual
objects, their relative positions and dynamic characteristics.
Subjectively, our ‘visual imagery.’
d) Meaning and two semantic codes
(8) Propositional (PROP):
A description of entities and relationships in semantic space conveying the
attributes and identities of underlying referents and the nature of
relationships among them.
Subjectively, specific semantic relationships (‘knowing that’).
(9) Implicational (IMPLIC):
An abstract description of human existential space, abstracted over both
sensory and propositional input, and conveying ideational and affective
content: schematic models of experience.
Subjectively, ‘senses’ of knowing (e.g., ‘familiarity’ or ‘causal relatedness’
of ideas), or of affect (e.g., apprehension, desire).
Propositional
– twig / snake
https://www.youtube.com/watch?v=gw
d-wLdIHjs
Evolutionary Context
Le Doux 1996 suggest there are two processing routes – quick and dirty
(low road) crude amygdala fear appraisal leading to an automated alarm
signal to the brain and body that sparks off freeze/ fight/ flight responses
and
Clean and slow (high road) where same data comes through the thalamus
and neo cortex
Conscious recognition of flight and fight ‘switch on’. The short amygdala
route works twice as fast the thinking neo cortex often too slow to prevent
the generation of emotional response e.g. amygdala spider threat – neo
cortex, ‘ it’s the stem of a tomato no need to panic’.
Schematic Propositional Associative
Analogue Representational systems
Approach (SPAARS)
APPRAISAL
SCHEMATIC MODEL LEVEL
Survival goal threatened
Bear
EVENT
ANALOGUE LEVEL
Image of Bear in Woods
PROPOSITIONAL LEVEL
“The Bear will eat me”
INTERPRETATION
EMOTIONAL
PRODUCTS
and OUPUT
SYSTEMS
Schematic Propositional Associative
Analogue Representational Systems
Approach (SPAARS)
– Goal directed
– Multi level theory
SPAARS
1 = Propositional Route
SCHEMATIC MODEL LEVEL
2= Direct Analogical Route
ANALOGICAL LEVEL
Bodily sensations
2
ASSOCIATIVE LEVEL
1
1
SPARRS AND PANIC
PROPOSITIONAL LEVEL
“I am feeling dizzy and will faint”
PRODUCTS
OF PANIC
Implications for Practice
– Meta models which can be used to understand many
different disorders, PTSD, OCD, Panic, Anxiety States,
Phobias etc.
– Understanding of theories can aid functional analysis of
clients difficulties
– Understanding of memory functions and processes can
be used to explain differences between cognitive &
emotional knowing
– Negates intra-psychic blaming of client
– Gives account of uses of emotional states
ACTIVITY 1. CASE STUDY
Shane is a 24 year old single man who lives with his parents.
His father is an alcoholic with a history of violence to his
family. Shane has over the last two years following a road
traffic accident started to dissociate in response to any
life stressors and over the last year he has started to self
harm as a way to reduce his anxiety and stress. There are
no symptoms of PTSD, but he does report feeling low in
mood.
FORMULATE THE ABOVE USING ICS AND SPARRS – Be
creative as to other background details etc
Time 20 minutes
ACTIVITY 2. Therapy PLAN
Based on your formulation for SHANE:
1.Draw up a therapy plan.
2.Consider the issue – do the different
theories lead you to come up with the
same or similar strategies?
3.What do these formulations add to more
disorder specific formulations?
ACTIVITY
- Identify a case complex case that you are
working with, then critically evaluate the
formulation or theory that you have used
by using either SPAARS or ICS.
- Reformulate the case and draw up the
therapy plan.
- Consider the similarities and differences.
CBP Assessment of
PTSD
Context
 Environment must be safe.
 ‘Obvious empathy’.
 Share anger, horror, disgust
 Therapist should be comfortable with the details.
 Containing.
 Identify concerns re ‘burdening’.
 Sessions longer when doing reliving.
 Supervision and support for therapist is
essential.
Assessment
 Comprehensive treatment of PTSD requires thorough and on
going assessment
 Critical in developing appropriate treatment plan
 Goal of the assessment is to
 Build rapport
 To assess PTSD and associated problems
 Determine and validate clients perception of their problems
 Avoid overwhelming yourself with information that is not helpful
 Develop an understanding of the impact on them today – how has
their life changed
Assessment
 Current problems:
 how do they describe their current problems
 Collate enough information regarding the trauma without going into
detail
 Consequences of the trauma
 Assess co-morbidity – Axis I ad II
 Identify the impact, through SUD ratings, on the thought of telling you
their story
 do they connect or disconnect
Assessment
 Main cognitive themes:
- Beliefs about themselves, the world and others,
- worse thing about trauma?
- most difficult thing since trauma?
- meaning of having PTSD?
- main feelings?
- appraisal of ongoing threat?
 Explore ‘hot spots’:
- when most distressed
- moment when patient dissociates
Assessment
 Maintaining factors:
- coping with intrusions
- avoidance / triggers to re-experiencing symptoms
and high affect.
 Safety behaviours:
- attempts to control symptoms
- attempts to evade feared catastrophe
Assessment
• What do they understand about PTSD?
• Explore how they think that the trauma has effected them
• What does it mean to them to have PTSD?
• What are their main feelings?
• What is their appraisal of ongoing threat?
• The impact on relationships, work and other activities
PTSD Assessment
• Assess if the trauma has been processed,
cognitively, emotionally and physically.
Including:
• Intrusive memories
• Flashbacks / disassociation
• Nightmares
• Intrusive images
PTSD Assessment
Assess if the trauma has been processed, cognitively,
emotionally and physically. Including:
 Intrusive memories
 Heightened arousal
 Flashbacks /
disassociation
 Hypervigilent to danger
 Nightmares
 Intrusive images
 Startle response
 Feeling numb
PTSD Assessment
•
•
•
•
Culture
Reservations about treatment
Legal proceedings
Other agencies
• Goals
Measures
 Impact of Events Scale Revised – Horrowitz
 The IES-R is a 22-item self-report measure that assesses subjective
distress caused by traumatic events
 Items correspond directly to 14 of the 17 DSM-IV symptoms of PTSD.
 Respondents are asked to identify a specific stressful life event and then
indicate how much they were distressed or bothered during the past
seven days by each "difficulty" listed.
 The IES-R yields a total score (ranging from 0 to 88) and subscale scores can
also be calculated for the Intrusion, Avoidance, and Hyperarousal subscales
Impact of Events Scale Revised
 Item Response Anchors are 0 = Not at all; 1 = A little bit; 2 =
Moderately; 3 = Quite a bit; 4 = Extremely.
 The Intrusion subscale includes questions 1, 2, 3, 6, 9, 14, 16,
20.
 The avoidance subscale includes questions 5, 7, 8, 11, 12, 13,
17, 22.
 The hyperarousal subscale includes questions 4, 10, 15, 18, 19,
21.
 See hand out
CBP Treatment of
PTSD
Contraindications for therapy
 Behaviourally or emotionally very unstable:
- suicidal / homicidal
- very high levels of substance misuse
- significant anger control issues
- ongoing risk (you cannot discriminate if it is still going on),
including asylum seekers who may be sent back
- battered women still living with perpetrator
-occupations / subgroups at a very high risk of further trauma
- Active psychosis
-Medico – legal demand for treatment without desire to engage
for other reasons
Treatment of PTSD
Many methods of therapy have been developed for survivors of trauma.
All methods share the following guidelines:
 Therapy is individualized to meet the specific concerns and needs of
each unique trauma survivor, based upon careful interview and
questionnaire assessments at the beginning of (and during) treatment.
 Therapy focusing on the traumatic event is only carried out when
the person is not in crisis. If a person is severely depressed; suicidal;
experiencing extreme panic; high levels of dissociation; in need of drug
or alcohol detoxification; or currently exposed to trauma such as by
ongoing domestic violence, then these issues should be addressed first.
Treatment of PTSD
 There are four main principals of CBP treatment: Providing information on the nature, etc., of PTSD in the early
stages can be very useful and contribute to normalisation.
 Exposure (live & imaginal) – aims to evoke anxiety and
promote habituation. The exposure is to the memories of the
event itself as well as other avoided areas, e.g., the scene of the
road traffic accident.
 Cognitive restructuring – aims to modify automatic negative
thoughts, dysfunctional beliefs, etc.
 Anxiety management techniques – aims to teach the person a
variety of coping skills in order to manage anxiety and other
symptoms.
Treatment – general plan
 Socialising to treatment
 Re-engage with life
 Processing the trauma – If appropriate at this stage
 Anxiety management training / Exposure
 Cognitive restructuring
 Relapse Prevention
Treatment plan continued
 If required work is undertaken prior to processing trauma
 Managing Dissociation
 Working with Flashbacks

Dual awareness
Socialise to Treatment
 Rationale for treatment
 initial symptoms are a normal reaction to a
traumatic experience.
 initial coping strategies can act to maintain
symptoms.
 treatment involves reversal of maintaining
symptoms.
Socialise to Treatment
 Education
- normalise
- explain how memory works
- demystify procedures during / after
trauma e.g. how Paramedics /Police
work; how drugs work; explore effects
of injury on processing
Socialise to Treatment
 Thought suppression
- how
- why
- behavioural experiments
 Strategies for dealing with intrusions
 monitor quality and frequency of intrusions (take a
baseline)
*Need to identify if the client is fearful that not
suppressing intrusions will lead to panic.
Re-engaging with life
• Re- engage as soon as possible
•
identify and problem-solve obstacles
•
identify strategies to control avoidance
•
identify and begin to reduce safety behaviours
Processing Trauma
 Patient must be in a reasonable state to
benefit:
- Alert
- Sober
- Not facing unusual other stressors
 Therapist needs to carefully balance full activation
of memory and emotions with spotting meanings
and unhelpful strategies used whilst reliving.
Processing Trauma
Structure
Sessions 1-2 imaginal exposure to the entire event adding more
and more detail
Session 3 identify critical points (Hotspots)
Sessions 4-6 Imaginal exposure to critical points
Function of Reliving
 Promotes elaboration and contexualisation of
trauma memory
 Helps with identifying idiosyncratic appraisal of
trauma
 Decreases fear of the memory
 Facilitates discrimination between now and then
Reliving
 Reliving
- Provide rationale
-Replay as realistic as possible (eyes shut, in
present tense).
 Help patient focus / ‘stay with it’.
-Become aware of as much detail as possible.
-Demonstrate your support and empathy
Reliving
• Client relives the traumatic event
 First Person, present tense
 Include stimuli, response, meaning elements
 All sense modalities
 Rewind and hold
 Prolonged
Audio-taped
Reliving
 Start with entire event, then move
onto ‘hot spots’
 ‘Debrief’ from reliving
- Distress ratings (beginnings, end, hot spots’)
- Vividness rating
- Identify most troublesome feelings
- Meanings
- Reorient patient to current place and time
Reliving
- Ask client to close eyes
- 4-5 sessions
- 1st person / present tense
- After initial session, ask what client
did to distance themselves
- Record the reliving
Reliving
Making reliving work well
 Clients should have:
 fully understood and agreed with the rationale;
feel safe, in control, be behaviourally reasonabl
stable;
 have made preparations for the immediate
reaction to reliving.
Treatment of PTSD
- May cause 50-60% of patients to have worse
nightmares / intrusions initially
- If client has other major stressors, reliving
exposure can be postponed
- Reliving elicits shame / guilt responses
Eye movement Desensitisation
and reprocessing (EMDR)
 Developed in 1989 by Francine Shapiro.
 At the heart of EMDR is the notion that accelerated processing of
disturbing material can be directly facilitated at a
neurophysiological level using a variety of dual attention tasks. A
by-product of resolution at this level is cognitive and emotional
well-being.
 NB: This procedure should not be attempted without specific
training.
Eye movement Desensitisation
and reprocessing (EMDR)
•
In 1987, Dr. Shapiro was taking a stroll in the park and had some
disturbing thoughts flash through her mind. After moving her eyes
from side to side she noticed the negative feelings immediately
dissipate. She assumed that the eye movements had a desensitizing
effect.
•
Eye Movement Desensitization (EMD) was introduced in 1989, later
called (EMDR) Eye Movement Desensitization and Reprocessing
(1991) to reflect the cognitive changes that occur during treatment
and to identify the information processing theory.
Eye movement Desensitisation
and reprocessing (EMDR)
• When an individual becomes upset or in distress,
the brain cannot process the information as it
would normally.
• Some traumatic event or recurring situation
provokes intense emotions that become “frozen in
time” and “stuck in the information processing
system.
• Dr. Shapiro claims EMDR has a direct effect on the
way the brain processes upsetting material.
Eye movement Desensitisation
and reprocessing (EMDR)
•
No one can explain how it works.
•
You concentrate on a problem and move eyes by following a stick, a
light, or a finger.
•
Some say it unblocks the information processing system.
•
Others say it workby the restructuring of memory by a ping-pong effect
between the rights and left side of the brain.
•
It affects how the brain interprets upsetting materials
The Eight Phases of EMDR
1.
Client’s readiness for EMDR is assessed
- Treatment plan is laid out
2.
Make sure client has coping skills and is in a relatively stable
state
Stress-reducing techniques taught and mastered
Phase 3 through 6
• Target is identified and processed using EMDR.
• Client identifies positive beliefs and rates it from 0-10.
•
Client focuses on the image, negative thought, and body sensations
while moving eyes back and fourth following the therapist’s finger.
• Client instructed to notice whatever happens and let their mind go
blank and then notice thoughts, feelings, images, memories, or
sensations that come to mind.
• When client reports no distress related to the targeted memory
clinician asks them to think of preferred positive beliefs.
• Therapist checks with client regarding body sensations.
Phases 7 and 8
7.
Closure
Client keeps a journal
8.
The Next Session
Re-evaluation of work done and inquire
about progress made
Image Re-scripting
 Imagery - focussed treatment designed to alleviate
PTSD symptoms and alter abuse-related beliefs and
schemas
 e.g. powerlessness, victimisation, inherent
badness, unlovability, intolerability
Image Re-scripting
 9 Sessions (90 minutes to 120 minutes)
 Fully informed clients
 Information gathering, including suitability
 Treatment rational
 Exposure phase - imaginal re-enactment of the
trauma in its totality
Image Re-scripting
 Imaginal or reliving work includes verbalising
aloud what she or he is experiencing.
 Therapist must be supportive but encourage the
client to stay with the effectively changed imagery.
Image Re-scripting
 Re-scripting phase - incorporates into the imagery
a new scenario in which the adult self enters the
abuse scene to assist the child.
 Role of the adult is:
- rescue the child and protect from further abuse
-drive out the perpetrator (with others if necessary)
 Therapist remains non directive – socratic.
Image Re-scripting
 Ideographic measurement
 Rate 0-100%:
- to drive the perpetrator away
- adult to nurture the child
- vividness of the imagery
 Rest of session devoted to processing the session and
homework.
 A recording of the session is made and should be reviewed
twice daily for homework, SUDS are rated and episodes of
PTSD reactions recorded
.
Anxiety management
 Relaxation
 Exposure
 preparing them for exposure
 Construct a fear hierarchy
 Explain habituation
Cognitive Restructuring
 To teach the client how to systematically
replace unhelpful thoughts with more helpful
and realistic thoughts
Relapse Prevention
 Relapse prevention in relation to maintaining
improvement; handling future trauma; managing
urges to use alcohol and drugs, etc.
What is Dissociation
“Dissociation is the act of separating something from
your awareness. It is an important defence mechanism that
everyone has against becoming overwhelmed by the noise
and visual chaos of daily life. When things get too much, we
simply switch off pieces so we don't have to hear them, see
them, or know about them. Usually we don't actually decide
to do this. Our brain does it automatically for us. When a
child is being overwhelmed by the pain and fear of some
traumatic event like being beaten up or raped, she may use
dissociation to mentally escape a situation which she can not
escape physically. Children are especially good at this”.
Lambert, (2006)
Methods to Reduce Dissociation
 Dissociative disorders might not be uncommon.
 Rates as high as 11% in the general population
(Ross, 1991)
 15% in Psychiatric patients (Sax et al., 1993)
 88% in survivors of childhood sexual abuse,
(Anderson, Yasenik & Ross, 1993)
Methods to Reduce Dissociation
 Dissociative Amnesia – may be present when a person is unable to
remember important personal information, usually associated with a
traumatic event.
 Dissociative Fugue – may be present when a person impulsively
wanders / travels away from home and upon arrival in a new place is
unable to remember their past.
 Depersonalisation Disorder – feelings of detachment or estrangement
from one’s self or others.
 Dissociative Identity Disorder (DID) – formerly known as Multiple
Personality Disorder (MPD).
Methods to Reduce Dissociation
 For those who are able to access psychological, emotional
and/or somatic events during dissociation, the content of
flashbacks or traumatic memories can also be established in
the assessment.
 Kirk, (1989) argues this can an be achieved through:
- Diary Keeping;
- Interview;
- Observation in session or by significant other.
Methods to Reduce Dissociation
Outward signs of dissociation may be subtle:
- discrete movements such as tapping,
rubbing a limb, or gently rocking of the body.
Clients are often fearful of affect or
mistrustful of others. It can be helpful to ask,
“What will make this easier for you”?
Methods to Reduce Dissociation
Managing Triggers and Reactions
 With complex presentations, invest time in building
a working alliance /creating a safe environment for
the cognitive work to take place.
 Identify triggers, e.g. painful affect such as
profound sadness / or intense anger and predictions
of not being able to cope; perceptions of
dangerousness; perceived sexual talk or behaviours.
Methods to Reduce Dissociation
Planned Avoidance:
 Once triggers for dissociation are predictable,
plans can be made to avoid particular situations or
persons.
 This can help generate a sense of relief and
perhaps a sense of mastery and safety. They can
later choose whether or not to embark on an
exposure to the trigger(s).
 Planning, distraction and grounding skills can
help arrest the process of dissociation.
Methods to Reduce Dissociation
Distraction Techniques
 Can be used at an early stage to arrest an unpleasant
dissociative experience.
Refocusing: Client is required to concentrate hard on
some aspect of the environment such as the colour /
texture of curtains, the feel of the arms of a chair, titles
of books on shelf etc.
Methods to Reduce Dissociation
Grounding Words: An agreed word which brings
client back to the present. Clients name often
fulfils the function, (but check that name is not
one which evokes traumatic childhood
memories). Word could also be a place of work,
the current date, a partner’s name etc.
Methods to Reduce Dissociation
Grounding objects: Tangible and portable
objects which are pleasant and associated with
the present, e.g. small, soft toys, ‘stress balls’
or wooden eggs.
Herb bags can be particularly potent because
of the smell they emit.
Methods to Reduce Dissociation
Grounding Images: Mental image of a safe and
soothing place. Should gain be clients choosing
and comprise as many sensory modalities as
usual.
More absorbing if it also contained an
enjoyable routine. Images however need
rehearsing frequently and associated with a
relaxation exercise.
Methods to Reduce Dissociation
Grounding Phrase: Brief sentence or mantra
which reminds client of themselves in the
present and can be practised until it comes to
mind regularly.
Should be emphasised to the client that all
these strategies need to be over-rehearsed if
they are to be accessible during times of high
stress and vulnerability.
Methods to Reduce Dissociation
 Cognitive
restructuring to diminish the
‘predictive’ power of the trigger and negative
meaning of dissociative reaction, e.g.
“I must not feel emotion, this is a sign of
weakness”
 Education
on nature of cognitive distortions,
e.g. dichotomous thinking, catastrophic
prediction, overgeneralisation etc.
Methods to Reduce Dissociation
 Graded Exposure: Through learning
grounding skills and ways of managing
dissociation.
 Initial stages of exposure will promote
significant anxiety and grounding skills are
used simply as a way to tolerate emotions
in a controlled way.
 Potentially use imagery first to promote
feared emotional state, grounding skills
utilised to desensitise client.
Methods to Reduce Dissociation
 Develop a hierarchy of feared situations,
thoughts, images etc.
 Wherever possible, in vivo exposure should
be practised.
 The process may be prolonged in most
severe cases.
Treatment of PTSD
Process and relationship
Clear treatment rational
Engagement
Collaborative relationship
Clinical setting
Obtain feedback
Homework setting and closure
Treatment of PTSD
Engagement
Initially expect motivation to be poor
Increase motivation by:
 Credible rational
 Reinforcement of help seeking behaviour
 Explicit pros and cons of treatment and
solutions
 Finish sessions with short term goals
Treatment of PTSD
 Difficulties in treatment:
Non-engagement
Depression
Guilt
Anger
Pain
Injury
Bereavement
Vicarious traumatisation
Working with
Flashbacks
Grounding and Monitoring
Toolkit
 Putting on the
brakes
 5 senses including
object
 Safe place
 Reality testing
 Anchoring
 ANS arousal
vigilance
 Breathing
 Grounding
 Dual awareness
Why learn to ‘put on the
brakes’?
1. SAFE AND EFFECTIVE PRACTICE:
To ensure that the trauma is being processed and not retraumatising the client
2. CLIENT EMPOWERMENT AND RESPONSBILITY
To teach the client the skills so that they can choose when to
process the trauma and when to contain it. This restores
their confidence in their own ability to judge what is right for
them, to control and monitor themselves.
Safe Place
Creating a safe place:
Sight
Sound
Touch
Smells
Taste
Body Awareness
Anchoring
Deepen the experience
Anchoring points
Experiential exercise
Breathing to ‘ground’
 Teach breathing
 Invite client to breath
 Breath noticeably yourself and / or
encourage client to breathe with you
 Invite them to feel feet on ground or to
imagine breathing up through their feet
Objects to ground
Soft objects as less useful than objects with a
rough texture.
Fir cone
Velcro
Rough shell
Using the senses
If the client appears to dissociate, use the 5 senses.
You need a minimum of 2 senses to be present
within the client in order to know the client is not
dissociated beyond contact / psychotic.
E.g. ‘Nod your head if you can hear me.’ (tests both
movement and hearing)
Reality Testing
Are you safe now?
How likely is it that this will happen again?
Importance of Body Awareness
To be able to work effectively the therapist needs to know
when the client’s ANS arousal is high as this indicates
whether the client’s flight or fight response is switched on.
If their fight or flight response is switched on then the
processing is not taking place in the neo-cortex /
hippocampus as the amygdala is dominant.
Arousal vigilance
Monitoring the client’s physiology helps the
therapist to know how the processing is going and
whether to continue process or to stop and return
to a safe place or different conversation.
Over time the client will come to learn to do this for
themselves.
Monitoring arousal using the body
Discuss with the client their own awareness of
arousal symptoms and ask them to grade the
feelings on a scale of 1-10, inviting them frequently
to report on what level the feeling is.
Watch the client’s breathing, body movement or
lack of movement, changes in skin colour, loss of eye
contact, inability to hear or respond.
Dual Awareness
Dual awareness is taught by Dr. Babette Rothschild and can
be found in her book, The Body Remembers.
Psychological tools that were missing to meet the
overwhelming trauma are also usually missing to meet the
overwhelming flashback; otherwise it would not be a
flashback.
Integration under those circumstances was and is not
possible. Dual awareness is a tool to help prepare the client to
be able to process and integrate trauma.
What is Dual Awareness?
• When a client goes into flashback it is a sign that the client’s
experiencing self (i.e. their behaviours and emotions) is
having free rein.
• Under these circumstances, the client’s observing self (their
cognitions) must be awakened and called back into the therapy
room usually with a measure of authority (firm, but not angry)
from the therapist:
‘Look at where you are now. What colour is the wall here? What
colour is the rug? What kind of shoes do you have on right now?
What is today's date?’ etc.
What is Dual Awareness?
 •When the client has experienced the return of their
cognitions or observing self the flashback halting
protocol can be taught so that they can practice the
same process on their own.
 It is based on the principles of dual awareness,
reconciling the experiencing self with the observing
self.
 The client slows down their associative emotional
response from ‘quick and dirty’ (SPAARS model) to
allow the neo-cortex to catch up.
Flashback Halting Protocol
This usually will stop a traumatic flashback quite quickly. The
client says, preferably aloud, the following sentences filling in
the blanks and following the instructions.
• Right now I am feeling……..
Insert name of the current emotion, usually fear
• and I am sensing in my body………
Describe your current bodily sensations – Name at least three
• because I am remembering……….
Name the trauma by title only – no details
Flashback Halting Protocol
• At the same time, I am looking around where I am now
in…..
The actual current year
• here……
Name the place where you are
• and I can see……
Flashback Halting Protocol
•
Describe some of the things that you see right now in
this place
• and so I know…….
•
Name the trauma by title only again
• is not happening now/anymore.
Symptoms of ANS Arousal
•
•
•
•
•
•
•
Body Awareness
Body Scan (relaxed)
Experiential Exercise
Body Scan (aroused)
Experiential Exercise
Symptoms of ANS Arousal
•
•
•
•
•
•
•
Power poses
Using neuroscience to change body chemistry
• Reduces cortisol
• Increases testosterone
Amy Cuddy link
http://www.ted.com/talks/amy_cuddy_your_body_languag
e_shapes_who_you_are?language=en
Relaxing and tensing
Relaxing releases tension
But is by no means the only way to work
Tensing and strengthening exercises are found to be useful
in improving resilience.
Exercise
Laughter
This also changes physiology and brain
chemisty.
Post-Traumatic
Growth
Post-Traumatic growth
‘Suffering is universal: you attempt to subvert it
so that it does not have a destructive, negative
effect. You turn it around so that it becomes a
creative, positive force.’
Terry Waite
Survived four years in solitary confinement,
chained, beaten and subject to mock execution.
Post-traumatic growth
 Post-traumatic growth or benefit refers to positive psychological
change experienced as a result of the struggle with highly challenging
life circumstances.
 The term posttraumatic growth was introduced by two pioneering
scholars Richard Tedeschi and Lawrence Calhoun.
 This does not mean that trauma is not also destructive and distressing.
No one welcomes adversity. But the research evidence shows us that
over time people can find benefits in their struggle with
adversity. Indeed, across a large number of studies of people who have
experienced a wide range of negative events, estimates are that between
30 and 70% typically report some form of positive change.
What Doesn't Kill Us
by Stephen Joseph
After experiencing a traumatic event, people often report three ways in which
their psychological functioning increases:
1.
Relationships are enhanced in some way. For example, people describe
that they come to value their friends and family more, feel an increased sense of
compassion for others and a longing for more intimate relationships.
2.
People change their views of themselves in some way. For example,
developing in wisdom, personal strength and gratitude, perhaps coupled with a
greater acceptance of their vulnerabilities and limitations.
3.
People describe changes in their life philosophy. For example, finding a
fresh appreciation for each new day and re-evaluating their understanding of
what really matters in life, becoming less materialistic and more able to live in the
present.
People who Have Experienced PostTraumatic Growth Say Five Things
 1.) My priorities have changed; I'm no longer afraid to do what makes
me happy.
 2.) I feel closer to my friends and/or family.
 3.) I understand myself better, I know who I really am now.
 4.) I have a new sense of meaning and purpose.
 5.) I'm better able to focus on my goals and dreams.
As McGonigal points out, these are essentially the opposites of the Top Five
Regrets of the Dying, which led her to ask herself, "How does trauma
unlock our ability to live a life with fewer regrets? How do you get from
trauma to growth, or better yet, is there a way to get all the benefits of
Post-Traumatic Growth without the trauma?”
Resilience
There are four kinds of strength or resilience that can facilitate
Post-Traumatic Growth, and there are scientifically-validated ways
to practice developing these resiliencies.
Physical resilience
Mental resilience
Emotional resilience
Social resilience
Vicarious Traumatisation
1
What is Vicarious Traumatisation?
• How does it happen?
• What are the symptoms?
2
Diagnosing Vicarious Traumatisation
3
Preventing / healing Vicarious Traumatisation
Vicarious Trauma
“There is a soul weariness that comes with caring. From
daily doing business with the handiwork of fear.
Sometimes it lives at the edges of one’s life, brushing
against hope and barely making its presence known. At
other times, it comes crashing in, overtaking one with its
vivid images of another’s terror with its profound
demands for attention; nightmares, strange fears, and
generalized hopelessness.”
B. Hudnall Stamm, Ph.D.
Vicarious Trauma
 Vicarious trauma is the process of change that happens
because you care about other people who have been
hurt, and feel committed or responsible to help them.
Over time this process can lead to changes in your
psychological, physical and spiritual well-being.
(Headington Institute)
Vicarious Trauma
 Cumulative –happens over time as you work with
survivors of trauma, disasters, people who are
struggling.
 Process of change is ongoing – this is hopeful as it
provides opportunities for us to recognize the
impact the work has on your lives early and to
develop strategies to protect and care for
ourselves.
Vicarious Trauma
Empathy
 When you identify with the pain of people who have
endured terrible things, you bring their grief, fear,
anger, and despair into your own awareness and
experience.
 What sort of problems or people do you find it
easy (or difficult) to empathize with?
 What are some ways that caring about people
who have been hurt affects you?
Vicarious Trauma
Feeling committed or responsible to help

A commitment and sense of responsibility can lead to
high expectations and eventually contribute to feeling
burdened, overwhelmed, and hopeless/helpless.

It can lead people to extend themselves beyond what
is reasonable.

How does your commitment and responsibility to your
work help you?

How might it be hurting you?
Vicarious Trauma
Understanding risk factors:
Personality and coping
style
Personal trauma history
Current life circumstances
Social support
Agency support
extending and receiving
assistance
Affected populations
response or reaction
Cultural styles of expressing
distress and Spiritual
resources
Work style – work/life
boundaries
Professional role/work
setting/degree of exposure
Signs and symptoms
 Feeling frustration or anger about a patient’s choices
 Thinking about a patient outside of work more than you want to
 Feeling anxious about working with a patient
 Feeling dread when you anticipate seeing a patient
 Feeling more worried than you think is necessary about a patient
 Feeling angry at a patient
 Feeling de-skilled or incompetent when you meet with a patient
 Taking on too much responsibility- difficulty leaving work at end
of day – stepping in to control other’s lives
Signs and symptoms
 Feeling disconnected or dissociated from the patient, their
emotions or the content of the session
 Having physical discomfort or pain while meeting with a patient,
which seems connected with what you’re working on
 Having other physical reactions to a patient’s stories, e.g.
increased heart rate, rapid or shallow breathing, nausea, feeling
frozen etc.
 Feeling traumatized after talking with a patient about specifics of
their abuse
 Wanting to cry during/after meeting with a patient
 Feeling helpless about your work with a patient
 Feeling enraged at a patient’s perpetrators
Vicarious Trauma
can impact people in the following ways:
 Coping mechanisms become overwhelmed;
 The effectiveness as a caregiver is reduced;
 Feeling helpless;
 Detachment from co-workers not involved in the work;
 Detachment from family and friends;
 Shortened tenure as service provider.
154
What are the results of
Vicarious Trauma?
 It contributes to feeling burdened, overwhelmed, and
hopeless in the face of need and suffering.
 It leads people to extend themselves beyond what is
reasonable for their own well-being.
 It can bring changes in spirituality which can, in turn, deeply
impact the way a people see the world and their deepest
sense of meaning and hope.
155
What is Vicarious Trauma?
 A gradual process that may unfold over time
 Cumulative effect of contact with survivors of violence or
disaster or other trauma
 Happens because a person cares (empathizes with
people who are hurting )
 An individual feels committed or responsible to help and
at times, cannot help.
156
Common Signs of Vicarious
Trauma
 Difficulty managing your emotions;
 Difficulty accepting or feeling okay about yourself;
 Difficulty making good decisions;
 Problems managing the boundaries between yourself
and others (e.g., taking on too much responsibility,
having difficulty leaving work at the end of the day,
trying to step in and control other’s lives);
157
Sleeping problems;
Isolation and disconnection
Nightmares;
Substance abuse and high risk
behaviors;
Intrusive thoughts,
memories and flashbacks;
Hyper-vigilance;
General anxiety and anxiety
attacks;
Changes in appetite and sex
drive;
Irritability and depression;
Cynicism, negativity, and
apathy about life and the
world.
158
Who may be most at Risk for
Vicarious Trauma?
People Who:
 Tend to avoid problems or difficult feelings
 Blame others for their difficulties,
 Withdraw from others when things get hard
 Have experienced trauma themselves
 Lack connection with a source of meaning, purpose, and hope
159
 Have stress in multiple areas of life
Diagnosing Vicarious
Traumatisation
Inventories, questionaires and scales
Eg.
•
•
•
•
Preventing Vicarious
Traumatisation
• Understanding the function and impact of mirroring and
mimicry
• Unmirroring
postural unmirroring exercise
facial unmirroring exercise
• Understanding your own arousal
Arousal awareness exercise
Conscious Postural Imaging
Conscious facial imaging
Un mirroring
Experiential exercise
Other tools for preventing
Vicarious Traumatisation
Sensory anchors
Controlling univited images
Physical distance
Know yourself and your
history
Fashion and bling
Ocular defense
Body edges
Strengthening the observor
Nurturing / cleansing your
workspace
Self Care Exercise
1 List three or more things that you will pay attention to during
each session
2 List through more things you will do between each session
3 This three or more things you would do at the end of each day
or each evening
4 List three or more things that you will do at least one time
each week
5 List three or more things that you will do at least monthly
6 Now decide to things who will you discuss these plans with?
Self Care exercise step by step
List three or more things that you will pay
attention to during each session: position facial
expression breathing pattern body sensations
arousal level areas that need muscle tone self talk
1
List through more things you will do
between each session write some notes open the
window get a drink go to the restroom wash
hands stretch and tone up muscles do a cleansing
ritual listen or dance to music eat a snack
2
This three or more things you would do at
the end of each day or each evening port client
material into a secure container take a shower say
evening prayers yell at the car window talk to a
friend exercise read the paper watch some TV
read a good book change clothes
3
4
List three or more things that you will do at
least one time each week get exercise have sex
see a movie is it with friends or family do
volunteer work not related to my
employment get out in nature do something
artistic have the weekend free to do fun
nurturing things
List three or more things that you will do
at least monthly see your own therapist talk with
the supervisor take a minivacation have or attend
a party
5
Now decide to things who will you
discuss these plans with? Where will you post
your list so that you will see it and be reminded
to follow your plan?
6
ACIU