Trauma Processing

TRAUMA PROCESSIN

G

Revealing

the Healing

Lori Daniels, Ph.D., LCSW; former Counselor, Portland Vet Center

disclosure

• All statements made are strictly the presenter’s and do not reflect the thoughts, opinions, nor policies of the Dept. of Veterans Affairs.

• Acknowledgements: R. Scurfield, S. Tice, D. Smith; Readjustment Counseling Service (Vet Centers); all my clients

O, my good lord, why are you thus alone?For what offence have I this fortnight beenA banish'd woman from my Harry's bed?Tell me, sweet lord, what is't that takes from theeThy stomach, pleasure and thy golden sleep? Why dost thou bend thine eyes upon the earth,And start so often when thou sit'st alone?Why hast thou lost the fresh blood in thy cheeks;And given my treasures and my rights of theeTo thick-eyed musing and cursed melancholy? In thy faint slumbers I by thee have watch'd,And heard thee murmur tales of iron wars;Speak terms of manage to thy bounding steed;

Cry 'Courage! to the field!' And thou hast talk'dOf sallies and retires, of trenches, tents, Of palisadoes, frontiers, parapets,Of basilisks, of cannon, culverin,Of prisoners' ransom and of soldiers slain,And all the currents of a heady fight.Thy spirit within thee hath been so at war And thus hath so bestirr'd thee in thy sleep,That beads of sweat have stood upon thy browLike bubbles in a late-disturbed stream;And in thy face strange motions have appear'd,Such as we see when men restrain their breath On some great sudden hest. O, what portents are these?Some heavy business hath my lord in hand,And I must know it, else he loves me not.Shakespeare, W. (1594); Lady Hotspur Verse

Henry IV, Act II

Agenda:1. What trauma survivors have encountered.

2. A model of trauma processing & PTSD

3. Preparing the client for trauma disclosure

4. Questions for data-gathering in sessions

5. Tenacious Curiosity and the Ability to Not Bail (Early)

– Case examples: guilt/grief; guilt & % of responsibility; helplessness in nightmares

6. Goals of trauma processing & PTSD intervention

What many trauma survivor clients have encountered prior to coming into counseling –

and even within counseling programs Expectations: that their story is not going to be shared (“speak no evil” AND/OR that the provider doesn’t want to hear it (“hear no evil”) =COLLUSION OF SILENCE REGARDING TRAUMATIC EVENT...Client’s minimization of trauma impact (“see no evil”)

PTSD

TRIGGERS: subtle/ obvious

Intrusive Recollections:

Memories, nightmares, flashes

Physiological Hyperarousal

AVOIDANCE: quest for mood shift

American Psychiatric Association, DSM-V; 2013

Distorted & distressing

thoughts and mood

PTSD





Detachment: quest for mood shift Distorted &

distressing thoughts and

moodAmerican Psychiatric Association, DSM-V; 2013

PTSD





AVOIDANCE: quest for mood shift

INTE

RVEN

TION

INTERVENTION

INTE

RVENTIO

N


thoughts and mood

American Psychiatric Association, DSM-V; 2013

PTSD

INTE

RVEN

TION

INTERVENTION

INTE

RVENTIO

N

• Cognitive Processing• Dialectical &

Behavioral• Acceptance &

Commitment• Eye-Movement

Desensitization• Medication Mgt.

• Coming in for help• Psychoeducation• Social & vocational

• Medication• INTEGRATIVE

INTERVENTIONS• Merging multiple

methods• Includes emotional

focus processing of dilemmas & conflicts

BUT, what about the emotions & feelings one had during the trauma? And still has post-trauma when triggered?


thoughts and mood

10

Hearing about trauma =

Trauma history is protected information.

Trauma healing can occur if allowed to be revealed.

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Safe Place

SAFE PLACE Provides a healing context

Creating a space to build trust/ where survivors can allow themselves to be vulnerable:

• To disclose and process changes since traumatic event• To feel comfortable and not judged• Provide opportunity to fully express

grief/loss/sadness–Clients are questioning whether they are

safe with therapist.

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Strong Rapport

A bit about RAPPORT...• How can a therapist “soften” the

tension?– Know that clients are watching closely (for

reasons to discontinue; “Is this provider wanting to help me? Able to help me?”)

– Informal vs. formal approach: first name vs. Mr., Mrs., Dr., etc. • Depends on program, care provider context

– Standardized assessments vs. open interview (first impressions)

– Flexibility with first few appointments: interaction

• Part of rapport-building: – Friendly, non-judgmental tone, welcoming to your office,

explanation of how 1st interview, and subsequent conversations will “look”

– Ask early: “What kind of things are you looking to work on through (me/us/______(name of agency)?”

– Listen closely to specific problem areas– Share that you’re listening for whether you/program will

“match” with the needs stated by the client– Ask at the end of interview if the client has any questions;

ask also if they feel like they’d like to come back– Offer to share with them during next visit about what

PTSD diagnoses looks like, and the therapy role within PTSD.

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Remembering and telling the truth about terrible events are prerequisites both for

the restoration of the social order and for the healing of individual victims. Herman (1992)

Without thorough assessment and rapport building: PROTECTED INFORMATION regarding a traumatic incident may never be disclosed by a client to their provider.

Setting the foundation for trauma processing

• Education about PTSD diagnoses• Share about the goal of therapy

and counselor’s role– Discuss compressed/overly

controlled emotions

• Consistency and no surprises.

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Trauma Processi

ng

Eventual Goal:

INTEGRATIVE METHODS

Trauma Processing

25

Hearing about trauma =

One approach does not appear to fit for all clients

What is there to process?

GUILT

HelplessGRIEF

Dilemmas After Trauma

• Unpredictability of life and death• Unexpected Losses (multiple levels of grief)• Moral Complexities (incl. guilt)• Feelings of low self-worth

Boehnlein, JK (2000). Psychiatry and Religion: The Convergence of Mind and Spirit. Washington, DC: American Psychiatric Press

Preparing the client for trauma disclosure

• Provide basic information (use visual diagram) to share about PTSD symptoms: fill out specifics together

• Explain how you plan to intervene with current pattern

– “Why I do what I do.”

• Share diagram of emotions and truncated feelings

– “Why I do what I do... Toward feelings.”

• Watch their responses, reassess their understanding, are they on-board? Have they had this before? Validate discomfort. Clarify their goals for therapy. Reassure that doing heavy work too soon will not occur, but avoidance won’t either.



Physiological Hyperarousal:

Vigilance, anxiety, diffic sleeping/

thoughts about self and past incident(s)

Avoidance, Numbing:

Isolate, alcohol/drugs,

withdrawal; detached feelings

PTSD

TRAUMATIC EVENT OCCURS No resources to help survivor put that experience (share, feel)- left to own methods of copingYEARS LATER Survivor is probably experiencing increased trauma reactions due to TRIGGERS NOT BEING IDENTIFIED TRAUMA TRIGGERS:

Thoughts about self,

danger, old-script; EMOTION

S.

Despondent

DespairHelpless

Grief

Sadness Depressed

Low Disappointe

d

Fear Loneliness

Hurt, Solemn

Anger Irritated Agitated

Frustrated

Numb "Okay"

"Fine" No Feeling

Satisfied Confident

Optimistic Excited Thrilled

Enthusiastic Ecstatic Joyful

Acceptable range

VICE GRIP ON EMOTIONS AFTER TRAUMATIC EVENTS © Daniels, 2012

Where the rubber meets the road

• Once you have safe place, rapport, and context, how to distill out underlying issues

• Listen: very closely to language used by client while sharing

• Watch: affect as client shares• Use: Probing, summary, reflecting,

neutral affect, supportive body-language

QUESTIONS TO ASK THE CLIENT (assessing for context):• “How long have you had ____(symptom)?” • “How often do you have these thoughts?”

(frequency)• “When was the first time you felt like this

in your life?” (duration)• “How old were you when ___(incident)

occurred?”• “What emotions (feelings) are you

experiencing right now as you are sharing this?”


QUESTIONS TO ASK THE CLIENT (assessing for current response pattern):• “What do you usually do when

___(memory) arises?”• “Does ___ (behavior) work?” What effect

does that have for you? What function?” • “What emotions are you trying to

change?” • “Have you ever allowed yourself to feel

the emotions connected to your trauma?” (If so, what was that like?)


SIMULTANEOUSLY, QUESTIONS TO ASK YOURSELF: (gathering data via “watching” and “listening”) • “What is their

affect/body-posture/gaze?”• “Do I hear statements suggesting loss,

guilt, unresolved grief?” • “What statements of ‘I am’ can I infer

from what I’m hearing?”• “How old would I guess the client is as

they are talking with me now? (how they present themselves)?”


QUESTIONS/STATEMENTS TO THE CLIENT:• “What emotions are you aware of

right now? Where in your body are your feeling them?”

• “I notice that you are hunched over and looking down... What’s going on?” (wait wait wait for the answer)

• Combining assessment and observing: more information.


So many options: clinical intuition

So many options: clinical intuition

Watch/Listen:• Body posture, eyes• Statement about self• Specifics about

traumatic incident– Decisions made– Full context of situation– Use of outcome to

flavor decisions made during crisis

Therapist options:(just like they taught us in school – just mix it up)

• Summary• Reflection• Deeper level questions• Extra information/educ• Focus on emotions• Listen... listen, watch,

wait, listen more.– The whole time thinking

Tenacious curiosity + don’t bail too early.

What is the narrative I’m hearing? How is this being

shared? First time? Details? Context? Triggers? Resistance:

verbal, emotional? Emotions: Fear? Guilt? Grief?

Helpless? How to get “unstuck?”

TRAUMA STORY REVEALEDMore details sharedContext assessedEmotions identified“I -- statements” identified

Case: Mr. B - VN Vet (processing guilt and grief)

• Benjamin is a war veteran (65 y.o.) from VN; helicopter door-gunner; guilt about not retrieving the body of his friend (who was KIA during training mission in dangerous area).

– His narrative: “I should have gotten him... I have not allowed myself to grieve him yet b/c we didn’t get his body... I’m still angry about it... The Capt. Should have let me go – I’ve been on dangerous missions before... “

“What kind of person am I to leave someone behind?... Who did I become?”

– Prior to processing – a lot more information gathered (tenacious curiosity – full picture); all aspects of what he recalled were explored and assessed

• Example: He shared that he had been part of intelligence meetings, which were often accurate; his commander left for several minutes before telling the vet “no” about going to get his friend; reasoning for not being allowed to go changed (wider perspective).

– Processing using all information he provided

Case: Ms. M - VN Vet female w/MST(processing guilt)

• Marianne (63 y.o.) states that her decision to sign-up her ex-boyfriend on a helicopter for a base air-show resulted in him being killed

– Her narrative: “I got him killed...and I’ve never forgiven myself for that “

– Prior to processing – more information gathered (tenacious curiosity – full picture)

– Percentages of Responsibility questions asked

• “What have you been saying about yourself given this incident?” “How often have you told people that you feel this way?” “How has this effected your life?”

• (Gestalt) “Choose three people in this room and tell them how you’ve been holding yourself responsible all these years and the impact it’s had on your life”.

• Diagram produced: Processing using all information she provided

Diagram: before & after processing degrees of responsibility

“I’m 100% responsible, he’s dead because of me.”

Veteran who was isolated after the tragedy; told that

she was at fault by officers.

“I wasn’t the only one making decisions that day that caused him to get killed.”

The officers who arranged the air show

The politicians who visited

The helicopter mechanics

The other pilot of the other helicopter

The ex-boyfriend who coerced the vet to put him on

the manifest

The Veteran

The designers of the Cobra

Case study: (processing disempowerment, helplessness)

Mr. L, MST client with recurrent, traumatically-based nightmares, and lots of triggers

• Larry (61 y.o.), former Air Force, was on special duty at another base; took a nap in the barracks and was assaulted by another service-member who came into the room while he slept. Was threatened 2-3x during assault.– His narrative: “I didn’t move… and then I didn’t tell anyone what

happened… there was no one to tell…and I really thought he was going to kill me…”

– Prior to processing: identified more triggers (wood smells, larger men, being visible, feelings of out of control

– Original target symptom: recurrent nightmare 3x/week– Client completed CPT and PE at VAMC prior to Vet Ctr.– Nightmare therapy, action (Wii) therapy, sandplay with new nightmare

Case study: (processing disempowerment, helplessness)

Mr. L, MST client with recurrent, traumatically-based nightmares, and lots of triggers

Emotionally processing traumatic events: Goals

• Increased understanding of one’s own unique PTSD symptoms & triggers

• Reduction of hyperarousal & reexperiencing symptoms

• Reduction of distorted beliefs• Gain insight• Reduction of dysfunctional coping• Permission to have all emotions• Increased self-worth• Ability to control PTSD response

(automatic) toward reduced time/intensity of reaction.

NATIONAL CENTER FOR PTSDPILOTS Database

www.ptsd.va.gov

Health & Medicine

Trauma Processing