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Distress ReductionTechniques2007Forrest James and Chris Lobsinger
Program Support vs. Exposure?HorowitzTerr’s When remembering is not advisable Distress reduction and affectregulation. Watch Your breathing
Grounding and containment Five senses Where are my edges Strength and balance Sleep hygiene Nightmare protocol Containing Writing Technique Flashback protocolProgram
Horowitz MapTraumatic experience1. Outcry Phase2.Denial Phase3.Intrusive Phase4. Working through Phase
Terr’s Typing Type I: Single EventLess need to provide frame Direct work with trauma Type II: Repeatedly TraumatizedLess need to provide frame Direct work with traumaType IIA: Stable Background Ability to SeparateTraumas Less work on frame Direct work on traumaI = Single event , II = Multiple events, A =Stable background,B =Unstable background ,R = Resilience NR = No resilience
Type IIB: Unable to separate traumasBuild Frame before working with trauma Type IIBR: Unstable but resilientReacquaint client with forgotten orunder utilized resources Type BNR: Unstable and little resilienceBuilding resources is the therapyI =Single event, II Multiple events, A =Stable background, B=Unstable background, R =Resilience NR = No resilience
When remembering is not advisable If you have not established a strongrelationship. If the client is not familiar with therapy. If the client is engaging in out of controladdictive behavior, self mutilation, indanger of suicide, or homicide. If the client is under current life stressorsMastsakis, Aphrodite, Post Traumatic Stress Disorder, A complete treatmentGuide, New harbinger Publications ,Inc 1994
If the client does not have a support systemother than your self If the client is currently in the intrusive/hypervigilant phase of PTSD If the client has stated she or he does notwish to remember the trauma If the client is suffering a psychotic episode oris manifesting psychotic symptoms. If the client begins to talk about traumaduring the last few minutes of a session If the client has forgotten the memories theyhave just retrieved In beginning of thesession.
Culturally Sensitive Use ofTechniques Relationship proceeds technique Shared world view/ rational for technique. Client expectancy needs to raised Techniques may need to be adapted for theclients culture. Use of common factors model
Distress Reduction and AffectRegulation It is important to help clients to feel morein control of there affect and to help themregulate and control their negative affect. To reduce suffering To reduce the use of other strategies suchas alcohol/drugs, dissociation, andexcessive avoidance which inhibitrecovery.John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation andtreatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Two categories of distress and affectreduction. 1. Interventions for acutedestabilizing emotions. 2. Interventions that improvenegative emotional regulating John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation andtreatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Grounding principals Focus the client attention on the here andnow which is safe and predictable. Can be useful in emergency situational Be careful not to stigmatize the client byover dramatizing the situation
Basic Grounding1. Focus the client attention onto thetherapist and the therapy asopposed to internal processes. Shift closer to the client Speak clearly Be careful with touch/verbalinterventions are recommended.
2. Ask the client to describe his or her internalexperience ask them to label there internalexperience not in detail3.Orient the client to immediate externalenvironment.Use their name______________You are here_________safe in this room.This is the present not the past.Focus of the present not the past.
4. If indicated focus on breathingmethods if needed. 5. Repeat steps 2 and 3 and assess theclients ability and willingness tocontinue. John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptomsEvaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Practice Grounding In groups of three CTO client,Therapist observer. Role play a distressed client,Therapist while the observer help byprompting the therapist from thenotes.
Chronic Dysregulation When posttraumatic arousal anddysphoria are too intense theyinterfere with treatment andrecovery. Medication may be indicated butthey are not sufficient withouttrauma processing.
Relaxation trainingThere are two main approaches torelaxation training:1.Breathing2.Progressive relaxation: (clenchingand relaxing) Relaxation techniques are not likelyto be helpful isolation from traumaprocessing.John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide tosymptoms Evaluation and treatment Sage Publications Inc 2006 Thousand OaksLondon. New Dehi
General Affect Regulation Identifying and discriminating emotions When people are over aroused the ability toidentify and label emotions can be lost andthe client can perceive their internal state aschaotic and unpredictable. Asking the client to name their feelings Encouraging the client to know and labeltheir feelings should be an ongoing process.John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation andtreatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Identifying and countering thoughts thatantecedent intrusive experiences The trigger The memory The thought that came with thememory The current feeling Identify the negative cognition and asuitable counter cognition.John Briere Phd & Catherine Scott MD Principals of Trauma Therapy, a guide to symptomsEvaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehli
Practice In groups of three CTO Client, TherapistObserver. Take turns remembering a time whensomething triggered a memory for you. Identify the trigger , the memory, thethought and a countering thought. Don’t use any memory that is highlytraumatic
Trigger Awareness and InterventionIdentify the thought feeling or sensation asposttraumatic Does the TFS make sense given my currentcontext? Are these TFS to intense based on the currentcontext? Does this TFS carry with it memories of the past? Am I experiencing an altered state of awareness? is this a situation where I usually get triggered ?John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation andtreatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Evaluate the stimuli present in thetriggering environment and identifywhich is trauma reminiscent. “Findthe trigger” Construct an adaptive strategy Intentional avoidance Analyse trigging experience Increase supportive systems Positive Self talk Relaxation, breathing Strategic distraction John Briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptomsEvaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Resistance to Tension ReducingBehaviours TRB’S self mutilation, impulsivesexual behaviour, binging,purging, hold off as long as possible doing it to the minimum (only) Take a firm stand against harmfulTRBS Controlling TRBS should notsimply be seen as stopping badbehaviours but learning affectregulation.
Affect Regulation is Learned DuringTrauma Processing. Affect tolerance is learned throughcontrolled non overwhelming exposureand the increased ability to self sooth. John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptomsEvaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi
Watching Your Breathing Reduces Anxiety Improves CO2 balance and reducesflight and flight response. Involves a number of elements Can be practiced before it is needed Can be practiced in increasecapacity to focused on self
Get comfortable Take 3 deep breaths Breath into diaphragm Breath out through pursed lips to controlflow of air. While watching the second hand, seconddigits, on a watch. Alternatively countyour pulse.
While watching the second hand/digits,or counting repeat and relaxing word . The goal is to increase the amount oftime it take to exhale the breath. Don’thold your breath. The can be practice three time a daysuntil proficient.
Practice Practice the watch breathing as alarge group.
Five Senses Start with three deep breaths Start from the top down eyes, ears, nose,mouth feelings, outside, feeling inside. Concentrate on one sense at a time. Naming slowing and rhythmically what you see,hear….
Zones of Awareness Zone 1 Seeing Hearing Zone 2 Sensations feeling in body Zone 3 Thoughts memories Fantasies selftalkComplete the sentence” Now I am awareof….. In each zone for one MinRotating through zones.
Where are my edgesRothchild, Babette The Body Remembers Norton 20041. Feel your butt on the chair whattemperature is the chair? Is it thesame or different from your butt?Is the chair hard or soft Is yourbutt hard or soft? Can you tellwhere your butt ends and thechair begins?
2. Try to feel your legs on the insideof your jeans/short/pants. Is thematerial smooth or rough? Does itfeel nice against your skin or is itscratchy? Can you feel your wholeleg along the inside of the cloth ordo some parts disappear?
3. Feel your feet inside your shoes.Are they warm or cold. Move yourtoes around. Is there a lot ofspace or a little feel the part of theshoe that is against the bottom ofyour foot. Can you feel thedifference between the shoe andyour foot? Can you feel the bottomof your foot?
Practice Each person select one of theexercises to practice. The group will have ten minutes topractice individually Report back to larger group.
Sleep Hygiene Go to bed when you are sleepy and getup at the same time. Do not sleep in tomake up sleep, do not take naps. Set aside time for problem solving duringthe day, not at night. Do not lie in bed if you cant sleep get outof bed and do something distracting butrelaxing.
Do not use alcohol to help you sleep Avoid caffeine after 4PM no more then2cups a day. Do not smoke one hour before the sleep. Avoid sleeping tablets for long term use. Reduce noise in sleeping place Ensure darkness Ensure body comfort, hunger, warmth,pain control.
Exercise during the day but not beforebed. Create a bed time ritual every nightbefore you go to bed. Be aware of anything that can interferewith your sleep. E.g. pets, digital clocks… Management of Mental Disorders, World Health organization Collaborating center Vol2 Fourthedition 2004
Nightmare protocolBabette Rorhchild 2001 Today I have been really scared of…… So I might have a nightmare and wake upfeeling….. And my heart might beat fast, and I might beshacking or crying. If that happens I will tell myself is is because Iam remembering…. Then I will turn on the light and look around myroom and name the thing in the room that I see. And I will tell myself that I just had a nightmareand that …. Is not happening now.
Defusing Nightmares Keep a pen and paper by the bed Write out the dream/nightmare in detail. Rewrite the dream with positive ending Read the new dream with the positiveending to your self before bed.
Containing Writing Technique Combined compartmentalization and exposure. Deal with self at the top of page Write in same place and time. Write only for 5 minutes (use timer) Write about disturbing, sad thoughts 2-3 hours before bed.
Example deal:I will write for 5 minutes each nightat 700 about some thingdisturbing , or sad on the conditionthat if I do this then I will not havemy sleep interrupted or haveintrusive thought during the day.
If I have intrusive thought,feeling or dreams I will say tomy self Not now later. As agreeto. I will write about this for 5minutes a 7 but not now.
Flashback ProtocolBabette Rothchild 2001 Right now I am feeling… and I am sensing in my body… Because I am remembering… And at the same time, I am now in theyear… Here…….. (Name the place) and I can see….. and so I know…..that ….is not happeningnow./anymore
Points To Remember Exercise Here and now Body awareness Staying with the discomfort Not over whelming Self soothing Connectedness
Exercise In group of three Each member picks an exercise theywould like to practice. C.T.O. Client, Therapist Observerroles.
Exercise 11. Use Fisher’s Common Factors: The therapeutic relationship Shared world view Client expectations Ritual or interventionto describe how these were involved inwhile implementing the technique.
Exercise 2 Use Alliance model (Bond, Goal,Task) to discuss how developmentof bond and goal agreementsupported the task (ie, techniqueused).
References John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, aguide to symptoms Evaluation and treatment Sage Publications Inc2006 Thousand Oaks London. New Dehi Horowitz. M. Stress Response Syndromes, Aronson New York (1976) Rothchild, Babette The Body Remembers Norton 2004 Page 80 Mastsakis, Aphrodite, Post Traumatic Stress Disorder, A completetreatment Guide,New harbinger Publications ,Inc 1994 Management of Mental Disorders, World Health organization Collaborating center Vol2Fourth edition 2004