Men & Trauma: 5 Dynamic, Solution-Focused Questions to Use in Therapy

7 09 2017

Guest Author:

Daniel Lawson, LMHC, CASAC

man in therapy

 

 

 

 

 

 

“I am not what happened to me, I am what I choose to become.” –  Karl Jung

Jung penned these words in 1965, and I find myself returning to them often in my work. The intention of this blog post is to provide clinicians with tangible and pragmatic tools to enhance treatment effectiveness with men who have with trauma histories.  As a solution-orientated therapist, the tools I use are questions.

My hope is that in using these questions effectively with the men you serve, they become more of who they are, and less of who they aren’t.

QUESTION 1: “What has been the greatest accomplishment of your life?”

Whenever I do an initial intake, I spend at least five to ten minutes at the beginning of the appointment with this question.  Asking your client about what they have achieved, builds awareness of their patterns of success.  This also helps the client feel at ease and competent.

Naturally, this question also helps men build confidence.  Confidence in many ways is a requirement for successful goal formulation.  Confidence also decreases men’s fears about treatment and making change.

Sometimes, the client may respond saying that they have not achieved anything great in their life.  As the therapist, it’s important to add, “not yet.”  If a client gives that response, it becomes a very appropriate time to talk about goals and ask, “Well, what would you like to say someday is one of your great achievements?”

QUESTION 2:  “What helped you survive?”

Often times our work as a therapist is to reframe the experience of our client.  This question alters the client’s perception from a place of being a “victim” to being a “survivor.”  This creates different expectations and also allows the client to see that in fact they have done something valuable.  It may also allow them to see other strengths that they possess as well as ways to build upon them.

It is important to note that male trauma survivors may habitually destroy their own self-worth, abusing themselves and ruminating on past failures. This question subtly harnesses the power of positive blame, demanding the client to take responsibility for their success and good decisions.

QUESTION 3: “How do you think other people have gotten through something similar to you?”

One crucial element in maintaining the therapeutic relationship and achieving positive treatment outcomes is respecting the client’s theory of change.  This question begins a conversation about what the client believes about their diagnosis/prognosis and their preferred method for recovery.  This also empowers male clients, offering them a way to collaborate and contribute to their own treatment process.

Sometimes the answers clients give reveal the client has very little hope in therapy in general.  In those cases, it becomes more important to explore ways to increase hope before more recommendations are made.

Clinicians can also use this as an opportunity to task clients to do some “research” and identify people who have recovered from similar situations.  Stories of others’ success increase hope and motivation for change.

 QUESTION 4: “Since this all happened, when have you felt at your best?”

Traumatic experiences can alter our observational skills.  Often times, periods when symptoms are less intense (or absent) remain outside of our client’s awareness.  If a client has no clearly defined goal, or they seem to “complain” habitually in session, it is very useful to provide the client with observational tasks.

This question increases the client’s awareness of what is working in their life and has a meditative quality, allowing them to be more present for greater periods of time.  It also enhances confidence and hope that may set the groundwork for the client to begin communicating about future goals for therapy.  Remember that attention is a limited resource, so whatever your client focuses on gets bigger.

 QUESTION 5:  “Who do you feel closest to in your life?”

David W. Smith coined the term “Friendless American Male” during the 1980’s recognizing the consequences associated with disconnected men.  Many healthy men prefer to connect and socialize with each other through experience rather than dialogue.  In building a positive post-traumatic identity, men can benefit from the company and friendship with other men.

This question helps to identity places of support and connection already in place in the client’s life.  Each client is different and therefore patterns and preferences for connection may be vastly different.  However, this is a respectful way to enhance the client’s support network and enhance their awareness of their process of connection. Once recognized, it may be replicated.

Sometimes, clients may respond saying that they are close to no one in their life.  In those cases, it may be useful to ask them if there was anyone they were close to in their past. If so, how did they go about that process?

CONCLUSION

Remember that all people are patterns that persist.  Change the pattern you focus on, change the life you lead.  Have the courage to ask better questions with your clients.  Our lives are the answers the questions we ask.  Better questions can mean a better life for your clients.

SELECT RESOURCES

Post Traumatic Success: Positive Psychology and Solution-Focused Strategies to Help Clients Survive and Thrive by Fredrike Bannink 2014 (book)

101 Solution-Focused Questions for Help with Trauma by Fredrike Bannink  2015 (book)

American Psychological Association “10 Factors of Resilience”

Based on TIP 56: Addressing the Specific Behavioral Health Needs of Men KAP Keys for Clinicians (SAMHSA)   

 TIP 56: A Treatment  Improvement Protocol Addressing the Specific Behavioral Health Needs of Men 

 Grit: The Power of Passion and Purpose by Angela Duckworth (book)

Essential Research Findings in Counseling and Psychotherapy, the Facts are Friendly by Mick Cooper (book)

Video-“Facts are Friendly Pt 1” – Mick Cooper

Video-“Facts are Friendly Pt 2” – Mick Cooper

Video-“Facts are Friendly Pt 3”  – Mick Cooper

1001 Solution-Focused Questions by Fredrike Bannink (book)

Quick Steps to Resolving Trauma by Bill O’Hanlon (book)

BRIEF, an SF training institute in London

ICCE, a worldwide community dedicated to promoting excellence in behavioral healthcare services

Pennsylvania University  Positive Psychology Center (Seligman)

Penn University with positive psychology questionnaires (VIA Character Strengths Survey)

 Author Bio: Daniel Lawson, LMHC, CASAC, works in private practice in Buffalo, NY. He specializes in working with men to overcome issues with relationships, depression, anxiety, substance abuse, death of a child, childhood trauma, or feelings of anger. Dan is a passionate, eclectic practitioner and bases his practice heavily on a solution-focused approach to therapy.  As a result, many of his clients see the results they are looking for in less than six sessions. Dan also uses DBT, positive psychology, mindfulness, CBT, existential, motivational interviewing, and narrative therapy. When working with men, he focuses on restoring hope and connecting them to their ability to do what it takes to heal. In every session, clients leave with a plan to begin improving their life. In addition, Dan also specializes in supporting Catholic men and woman. He effectively combines his faith with his psychological training to provide therapy deeply rooted in Catholic Theology and Philosophy. Dan is a balanced professional and works effectively with his clients regardless of their spiritual/religious beliefs.  Prior to starting a private practice, Dan worked at Horizon Health Services for ten years. In addition to his clinical experience, Dan has experience in training provision and clinical supervision services.  Visit his websites for information at:

http://catholictherapysolutions.com

www.counselorscorner.net/clinicians.html

 

 

 





Got Barriers? Improving Access to Mental Health Care for Children & Adolescents

23 01 2015

Guest author:

Melanie Washington, LMSW, MPH, PhD candidate

  Child concerns on a corkboard

If it were not for social work interventions I had as a child, my life trajectory may have been completely different.  I am eternally grateful for those individuals who, with moderate intervention, helped to shape the individual that I am today and be a part of what facilitated the passion that I have for mental health care for children and adolescents.  With my life experiences, both personally and professionally, I fervently believe that every child deserves the opportunity to have mental health treatment, therefore it is my hope through my future work we will be able to figure out solutions to help increase access to mental health care for all children.

I had my first interaction with a social worker in second grade.  I was fortunate to have parents who recognized the struggle that I was having and were unconcerned about the stigma of seeking mental health treatment.  In general, I was an irritable, angry, and strong willed child, with a low sense of self-worth (it wasn’t until I was an adult that I was diagnosed with depression and learned that this is often how depression presents in young children).  However, at school, I was shy and quiet, allowing myself to be walked on by my peers and then I would come home and take it out on my family, verbally and physically.  It was through family and individual work that I was able to start making improvements and gaining more confidence in myself.

Then in sixth grade, I became well acquainted with the school social worker who assisted me in dealing with tremendous challenges and stress at home (although this time I was not the cause of it).  Her assistance and support shaped not only my personal trajectory, but also my career.

After obtaining my bachelors in social work, I worked as an intake coordinator in an outpatient mental health clinic for children and adolescents; I saw the heartache and immense challenges caregiver’s face in attempting to access treatment for their children.  Therefore, I made the decision to go back to school to become a researcher to find solutions to this issue.  I have also begun working on an exciting new grant funding a white paper exploring the issues of access to child and adolescent mental health care in Western New York.

Why is this issue important?

  • Children globally (1 out of 4) have at least one diagnosable mental health disorder.
  • There are not enough child mental health providers to meet the current needs within the population.
  • The World Health Organization has estimated a 50% increase in childhood mental health needs by 2020.

Closed Road with signs

Potential (and too often) Real Barriers:

  • Financial barriers:
    • Insurance coverage- plan may not include mental health services, minimal number of visits allowed, therapists may not be “in network”, may have high deductible plan
    • No insurance
    • Co-pays and families without money to pay the co-pay
    • Sliding fee scales- if they are offered, still may not be low enough for families to afford the payment
  • Geographic barriers: There may not be any clinics in the communities in which individuals live. If a child is below the age of 5, the family may have to travel further distances to find a therapist willing to see children under this age
  • Transportation barriers: Does the family own a car? Can they afford gas? If not, do they have access to Medicaid funded transportation or have money to take the bus? Is your clinic on a bus line? How many bus transfers would might families have to take to get to the office? Is there enough time for the family to take the bus to the appointment after they get out of work? Is the family ashamed or embarrassed to tell you that they don’t have the adequate transportation to access services?
  • Organizational barriers:
    • Hours of operation: Do the clinic hours of operation provide enough flexibility for days, evenings and weekend appointments or does the schedule of therapy create a barrier to access?
    • Does the clinic engage in practices of double booking that can cause people to wait past their appointment time when both appointments show up as scheduled and someone has to wait? These delays may not be tolerable for the children and adolescent or their family due to behavioral and schedule needs (such as the last bus leaves before their appointment ends).
    • Is there enough diversity in the sex and race/ethnicity of therapists so that families have a choice of someone they feel comfortable with?
    • Are there therapists who have appropriate specializations to work with diverse clientele in a clinic as well as evidence-based treatment skills to provide effective treatment?
    • Is the organization trauma-informed and trauma-sensitive so that people seen feel safe and welcome, and are not re-traumatized through service provision?
  • Availability of services:
    • Is a family able to easily obtain an appointment when they first call? If not, what does the process entail for a family to get one? How long do they have to wait for the first appointment? How are they treated by the person who handles the initial contact with the agency? Does the family feel cared for, engaged and that their social or cultural differences will be recognized and understood?
    • If an appointment is given, is it within a reasonable period of time?
    • Are there therapists available to take on new clients?
    • Are there delays or interruption in service being provided- for example if an agency has a high turnover rate, how long to families have to wait to see a new therapist when their current one leaves, and what impact might that disruption in services have on the child?
  • Lack of awareness and willingness to access care:
    • Caregivers may not recognize the signs that a child or adolescent needs mental health treatment. Or they feel there is a stigma related to this. How to we help educate them?
    • Caregiver may be unsure about how to access care, who to ask, and how to navigate the mental health system. Their primary physician also may not be knowledgeable about how to assist them. How do we help them find access to care?
    • Fear: Caregivers may be fearful that if their child does need mental health care that they will be blamed for their child’s behavior or that their child will be taken away from them. Social workers are often equated with Child Protection Services and the myth that CPS only takes away children from families. How do we educate families that therapists can help?

  Kids enjoying family timeThere are many barriers faced by families as they attempt to obtain mental health services for their children.  Yet I passionately believe we also have also have the ability to create some solutions for children and adolescents, their families, mental health care organizations, and the research and policy community.

Possible Solutions for Families:

  • Take action! If you are concerned about your child, talk to their primary care doctor or school social workers.
  • Keep a positive attitude: Help is available and the sooner mental health issues receive effective interventions, the healthier the outcome will be for the child and family.
  • Don’t worry: Getting mental health help for your child does not mean you are a bad parent!
  • Communicate (there is a questions at the end of this post to ask of different providers) with your child’s providers and advocate for them if you do not like the way services are provided. (There is a link at the end of this post on the family resource page with 25 ways to advocate for your child.)

 Possible Solutions for Organizations:

  • Improve engagement and retention of clients by following Trauma-informed Care (TIC) principles and educate all staff at the clinic, from the receptionist to the director on TIC. (Refer to the resource section at the end of this post.)
  • Review and adjust, if needed, clinic hours of operation to ensure they meet the needs of family schedules.
  • Attempt to hire a diverse group of individuals and provide training in cultural competency.
  • Advance the education of your workforce to enhance their skills in treatment provision including evidence-based treatments
  • Include access to services in agency strategic planning.
  • Review and adjust, if needed, your intake process. For example: is there a way to streamline it and make it more family friendly, decrease the waiting times for services, etc.?
  • Review and adjust, if needed, scheduling so that clinicians can see their clients at the time that their appointments are scheduled.
  • Pursue grants or a charitable fund to assist families who are unable to cover the cost of services, bus passes to get to the clinic, and other needs that create barriers to access.
  • Consider, if possible, performing home or school visits for families who have transportation issues.

Possible Large System Solutions:

  • Enhanced integration of physical and mental healthcare
    • Mental health screenings in pediatric clinics, starting from birth
    • Having mental health professionals on staff so that a child or adolescent screens positive they are able to see someone immediately, in addition to providing regular treatment
  • Enhanced integration of mental health clinics into schools or increase of therapists within schools who are able to provide regular psychotherapy, as opposed to crisis management
  • Evaluate tele-mental health: To assist with families to who have transportation issues or may not have easy geographic access to a mental health clinic. Yes, billable regulations need to be investigated and policy advocacy may be part of this with funding bodies.

 Resources:

New York Child and Adolescent Psychiatry for Primary Care

25 ways to advocate for your child

Questions for caregivers to ask providers

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

US Dept. of Health & Human Services. Access to Adolescent Health. Access to Mental Health Care

American Psychological Association. Strengthening the Child and Adolescent Mental Health Workforce

American Psychological Association. Increasing Access and Coordination of Quality Mental Health Services for Children and Adolescents

Photo Credits

Closed Road with Signs

Child Concerns on a Cork Board

Piggy Ride Time, Kids Enjoying





Behind the Human Curtain: The Courage to Look

2 11 2014

Wow…I was blown away when I read In the Ogre’s Lair: Seeing Light in Shadow by J. Scott Janssen, LCSW, in The New Social Worker Magazine. Scott tells a powerful story of helping a challenging client who was hiding behind his ‘curtain’, behind a very big and intimidating wall. What a blessing it was for this man’s life and for his transition into death that Scott persisted in providing support, even though it was a very stressful relationship. So much of what happens to our clients remains hidden. Sometimes when we consistently present ourselves as compassionate, sensitive and trustworthy people, the curtain will slowly move away-  just enough to allow room for hope and help to slip in.

Through his skillful storytelling In the Ogre’s Lair: Seeing Light in Shadow, Scott shares his experience with us and I included an excerpt below.

Read the full online article here.

I should have seen it coming when I slipped on the bullet casings strewn across the front steps. Or when I rang the doorbell and heard an angry-sounding voice bellow, “Who are you and what do you want?” I identified myself as the hospice social worker and waited…

“I don’t need a social worker,” he growled.

I’d read his medical history—respiratory disease, diabetes, hypertension, skin ulcerations that just wouldn’t heal, a long history of uncontrolled pain. And a single line entered under “Social History”—patient can be hostile and combative.

Our visit that day consisted mainly of him telling me what a bunch of incompetents his medical team had been and why it was their fault he was in such bad shape. He alluded to talks he was having with his lawyer and how he would “settle with those cranks” before he died. He came across as angry, self-righteous, and abrasive. And, yes, hostile and combative…

The visit tension hit its high note when I asked if he was having any suicidal ideation. It was a reasonable question—an ex-cop with guns, over sixty-five, male, socially isolated, terminal illness, secretive, hyper-vigilant, apparent anger issues, wanting to be in control but facing increasing physical decline, protective of his privacy but needing help, possible impulsivity, possible depression, possible aggression, possible PTSD—but Jack didn’t see it that way. He hit the roof.

Over the next many months, I called him regularly and offered visits, bracing each time for rebuff and/or complaint…No conversation, however, remained civil for long. He always found his way back to things about which he was angry, always went back on the attack…

Funny thing was, despite his sarcasm, complaining, and opposition to almost everything our nurses suggested, Jack’s medical condition was stabilizing. Steady care from our staff and Jack’s reluctant willingness to listen to a few recommendations here and there allowed his wounds to begin healing. His blood sugar was controlled, and so was his blood pressure. He even began taking more pain medication and getting more sleep at night. Taken together, his underlying respiratory disease began appearing more chronic, less terminal…

When Jack was finally discharged from hospice service because of this stabilization, I was relieved. I walked away thinking I knew him, thinking I’d seen him, and glad to be done with him. As far as I was concerned, he was an egotistical bully. He was insensitive, foul-tempered, devoid of empathy as well as the most remedial signs of social or emotional intelligence. Although I admired the determination and discipline it took to live alone with all the challenges he faced, these were no excuses for being a mean-spirited, anger-addicted pain-in-the-neck…

Sometimes I felt relief that I’d never see him again. At other times, I had a sense of dread that sooner or later, he’d be back…

On the morning I saw his name once again listed under the previous day’s new admissions, I swallowed hard…

The visit was to be our last. I walked in, and Jack was awake. He smiled wide and held out both arms as if to hug me. My first thought was that he was confused. “Hi, Jack. Remember me?”

His smile broadened (something I’d never seen before), and he said, “My social worker.”

He clasped my hand and continued holding it throughout the visit as I sat beside the bed. “I feel so much better now that you’re here,” he said.

Masking my surprise, and wondering if he was being sarcastic or setting me up, I asked him about what had been going on recently.

“It’s been a hard time.” His eyes appeared to water slightly, “I think I might be dying.”

No secretiveness, no defensiveness, no complaints, no blame or attacks… His memory and concentration were taxed, and he had a hard time finding words, but slowly, methodically, Jack searched for language to describe and process what he was experiencing…

Read the full online article here.

Other Resources

Janssen, J. S., (2004) Dawn is Never Far Away: Stories of Loss, Resilience, and the Human Journey

Janssen, J. S., (2013) Locked in the Vault — Survivor Guilt in Combat Veterans, The New Social Worker Magazine

Janssen, J. S., (2012) Just Plain Stephie: Conversations at the End of Life, The New Social Worker Magazine

The New Social Worker- free e-magazine www.socialworker.com

Lacay, S. (2013) Breaking Boundaries With Empathy: How the Therapeutic Alliance Can Defy Client/Worker Difference, The New Social Worker Magazine

The Therapeutic Alliance: An Evidence-Based Guide to Practice (2010)

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Creative Commons Attribution: privatenobby flickr.com




Improving the System for Our Loved Ones: A Mother’s View of Addiction and Services

16 07 2014

Depressed teen free Morgue file

Guest author: name withheld for confidentiality

The day before Christmas, I received a phone call from my oldest son asking me to pick him up on a downtown corner in a risky neighborhood. He gets in the car wearing sunglasses even though the day is dark and cloudy.  My inner alarm sounds and my heart starts to tear… he is high again.  Back home I watch him slowly begin to detox. How many times does this need to happen?  My rule is that he can stay at home as long as he is willing to get help. Of course he agrees as he has nowhere to go. We plan to go to a local hospital inpatient unit but you have to be in a certain physical state to get admitted, and this depends on who is doing the intake and bed availability. Sometimes he can be admitted, sometimes not- yet he is the same person each time, out of control and in need of addiction treatment. We have to wait until Christmas morning to go there.  Not exactly my plan for a family Christmas but I am prepared to do whatever it takes to save his life. 

We arrive at the inpatient unit only to have him turned away. They say he is not sick enough. Really? He is an out of control addict using heroin, asking for help and I am terrified he will die. So now what?  He can’t come back home and refuses to go to a different hospital inpatient unit to see if he can be admitted there. So he decides to stay with a ‘friend’ as he cannot stay with me if he is not in treatment- it is too risky for my family because of past incidents. I drop him off, not knowing what he will do next and the heartache I feel is overwhelming.  What kind of mother turns her son out Christmas day? I feel like I am living in a perpetual grief state as I wait for the worst to happen.  Will this be the last time I see him?

It wasn’t always like this. His childhood was blessed- large and loving family, many friends, fun activities, and strong church involvement.  He graduated near the top of his high school class and attended a private university. But drugs don’t care if you have a college degree.

 Drug use. addictionImage courtesy of Victor Habbick-FreeDigitalPhotos.net ID-10073274I was told people can have the potential to be an addict long before they touch a drug.  This is true of my son.  He is very creative with an eccentric personality that is so fun yet always intensely, sometimes obsessively, focused on the current interest. When he latched onto a new interest that was not so healthy, the consequences became deadly.  After having suffered several major psychological traumas in his late teens, his addictive personality took over to stop his thoughts and feelings.  First it was alcohol, then marijuana, then pain killers finally escalating to heroin. The lies, the deceptions, the thefts from family and friends could no longer be ignored but I was determined not to lose my child. The service system is far from perfect and whether or not your child is receptive to help makes a difference.

older woman head in hands free morgue fileI have had people telling me to cut him off, let him hit rock bottom, and move on in with my life. And a few who said never give up on your child. How can I move on in my life when my son is a big part of it and needs help?  I also walked a fine line trying to avoid being the enabler. I struggled with every decision and often doubted if my choices were right.  Rock bottom can mean death. Will this push him to suicide or will he survive the next overdose? Will he start cutting his arms again? I have cried my eyes out over this, made myself physically and emotionally sick with worry and stress, mourned his death over and over, and planned his funeral.

Twice he was kicked out of inpatient residential programs for not following the rules leaving him with no place to go. How did that help him? He also quit seeing several outpatient therapists because he was smart enough to recognize their insufficient skills or they lacked the rapport needed to keep him in treatment. I have had him arrested, requested a three-day hold in psychiatric unit, cut him off financially, visited him in jail, begged for the best treatment placements through the drug court, taken him to therapy, attended NA meetings with him- often to no avail. I watched him make gains in his recovery only to relapse and have to start over. I remember when I first admitted to friends that he was an addict, I was told that expect him to relapse.  I was stunned by this statement- not my kid, he can do this. I was so wrong as the addiction was more powerful than my amazing, talented son.

 If I could offer any advice to families walking in my path and the service system, it would be:

 

  • For families, please persevere.  Ask many questions, seek help, get therapy, cry if you need to, get mad, and be prepared to fight the battle of your life. Give them hope when they are unable to do it for themselves.
  • Always believe in the person battling an addiction and never give up on them. Be compassionate and persistent even in the face of lies and relapses.
  • The addiction service system needs to find improved ways to meet the needs of people who are up sick and desperate for treatment.
  • Please stop turning them away from treatment saying they don’t meet criteria, or there is no room and giving them no place to go when they are sick and desperate.  
  • Find better places for residential treatment homes so they are not close to ‘crack’ houses that create great temptation.
  • When they keep their cell phones in residential treatment their dealers are still calling them- another temptation that could be avoided.
  • When they are in drug court, break the rules for participation and get throw out of treatment,  why are they immediately discharged from treatment on their own  and not turned immediately back over the custody of the courts?  They do eventually get re-arrested but the time in between can be deadly.  This is a big gap in the program that needs to be fixed.
  • Trauma and addiction go together as I saw this with my son. Psychological trauma is often part of why the person is addicted and both parts of who they are need to be treated as the drugs never go away as long as the emotional pain is still there. So intertwined, yet many of the counselors I interacted with did not have the skills or knowledge to provide effective treatment. I am told this is called a dual-disorder. Agencies need to support staff in gaining advanced treatment skills.
  • Remember that the family is suffering, too. My son’s addiction traumatized all of us. Family members need support. Whether you are a friend, family member or service provider, please understand and empathize with the feelings of shame, sadness, anger, guilt, embarrassment and helplessness we feel. The effect of addiction is devastating and the impact on families and friends is horrific, widespread and so long lasting as trust is often irreparably broken.

Epilogue: As of this moment, my son is in recovery and making progress with the support of a very skilled trauma and addiction therapist. I hope and pray each day that healing and recovery continue. Yet part of me still is still scared, still holding my breath each time the phone rings…

Resources:

New York State Combat Heroin & Prescription Drug Abuse http://combatheroin.ny.gov/

National Institute on Drug Abuse www.drugabuse.gov

Narcotics Anonymous www.na.org

Alcoholics Anonymous www.aa.org

Nar-Anon Family Groups www.nar-anon.org

National Council on Alcoholism and Drug Dependence www.ncadd.org

SAMHSA evidence-based treatments for addiction http://www.nrepp.samhsa.gov/SearchResultsNew.aspx?s=b&q=addiction

SAMHSA Co-Occurring Disorders http://media.samhsa.gov/co-occurring/

National Center on Trauma and Trauma-Informed Care http://beta.samhsa.gov/nctic/trauma-interventions

Photo credits:

Woman and teen photos from www.morguefile.com

Drug photo credit- Drug and addiction use courtesy of Victor Habbick at www.freedigitalphotos.net





Perfectionism: stalker, hunter, destroyer

19 03 2014

Wolf And Moon

Perfectionism, with its burden of dysfunction, guilt and shame, is not always just a client issue. As therapists, supervisors and other human service professionals, we need to be self-aware if this stalker lives within our own mind and body. We cannot help others heal if perfectionism has us by the throat. It will choke our compassion, patience and efforts to maintain a nonjudgmental approach. We also need to understand the importance of recognizing signs of perfectionism in our clients as it is often lurking in the shadows, not always obvious.

I was inspired to write about this topic because I saw a blog post that included a poem titled The Big Bad Perfectionist.  It was their introductory quote that moved me: “We all have a big bad wolf inside of us. A beast who lurks behind the happiness and success in our lives. My big bad wolf is my perfectionism. I hate him. He stalks my every move and haunts my thoughts, but I refuse to let him destroy me.”

What is perfectionism really about?

  • Perfectionism is common and often thought of as personality traits setting excessively high performance standards with very critical self-evaluation. The end result can be high levels of stress, anxiety, obsessive behavior, dysfunctional relationships, low self-esteem and more. Jeffrey Young’s Schema Focused Therapy identifies schemas or “lifetraps” we carry in the core of our being including the “unrelenting standards” lifetrap that fits well with perfectionism.
  • In “Overcoming Perfectionism” by Ann W. Smith, she defines overt and covert perfectionism.  According to Smith, a person with overt perfectionism is likely to enjoy order and structure from an early age. This tendency is not necessarily attributable to low self-esteem, insecurities, etc. Those who are covert are described as “closet” perfectionists and harder to identify, full of inner “shoulds” and pain as they carry around the critical inner parent- stalker, hunter, destroyer of their quality of life.
  • And what about the relationship between trauma and perfectionism? If you see someone with perfectionism issues, do you consider this as a possible clue to a trauma history that needs to be assessed? Was their childhood filled with experiences with caregivers dictating the expectation for perfection through words and behavior? Experiences that made them feel they “failed” countless times in the eyes of the caregiver? These are lyrics from a song by Libby Roderick: “How could anyone ever tell you, you were anything less than beautiful? How could anyone ever think, you were less than whole?”  For those who feel they should be perfect and cannot achieve those standards, it can be heartbreaking as they internalize the constant trauma and pain of failure. The lyrics speak to the heartache and distress of being regarded as imperfect, defective that is so often a part of the covert style. Signs of covert perfectionism need to be attended to and explored to help the person heal. Look, listen and remember the person often is not aware of their inner demon critiquing and destroying them.
  • Perfectionism can be generational as a caregiver teaches it to the child who grows up without saving/healing themselves and then passes it on, unaware, to their children.
  • Shame and guilt may be deeply felt due to a person’s inability to achieve that elusive standard of “perfect”. They are ashamed that they are never good enough for the person, or persons, who set the standards for the “shoulds”. If this started in early childhood, the core of their being may feel worthless, of no value. Shame can live in the body without words to name it.
  • Perfectionism is a complex issue that can range from enabling a person to become very high achieving and successful (but at what price?) to causing on-going stress, anxiety, depression as well as dysfunction in relationships. Deeply entrenched as part of a trauma history, it can lead to self-destruction.

What to do?

  • Perfectionism is common so listen with an open heart and offer thoughtful, gentle engagement and treatment to those who come for martial counseling, depression, anxiety, stress, co-occurring disorders, eating disorders, anger management, substance abuse treatment, PTSD and more. Those with covert perfectionism may be unable to identify themselves has having perfectionism or unrelenting standards. It is all they know, all they think the world should be, so to be anything less than how they live is to move to what they define as an incompetent level of functioning. Listen for their “shoulds”, for their unrelenting standards and help them shift/reframe their thinking as you help them heal.
  • Reflect and address your own levels of perfectionism as this will impact on your client relationships if your overt or covert perfectionism is present in the therapeutic relationship.
  • Advance your skills by reading current literature, identifying appropriate assessment tools and treatment approaches that can bring this issue to the surface with greater clarity and help the person heal.
  • While a quick web search turned up many links for Cognitive Behavioral Therapy and its use with perfectionism, also consider other approaches when this core belief is deeply entrenched from childhood stresses and/or traumatic experiences.  CBT can be  frustrating for some people when it feels as if its approaches are in an endless battle against unprocessed painful or traumatic memories. For some, CBT may feel more effective when the traumatic memories are resolved through evidence-based trauma treatment.

Select Resources

Schema Therapy Institute http://www.schematherapy.com/id201.htm

Cognitive Behavioral Treatment of Perfectionism http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/egan.htm&dir=pp/ad

When Perfect Isn’t Good Enough: Strategies for Coping with Perfectionism http://www.amazon.com/When-Perfect-Isnt-Good-Enough/dp/157224559X/ref=dp_ob_title_bk

The Surprising Reason We Beat Ourselves Up (and What to Do About It)- Social Work Career Development Blog http://www.dorleem.com/2013/05/the-surprising-reason-we-beat-ourselves.html

Author: Lesa Fichte, LMSW, Director of Continuing Education

Photo Credit: Wolf and Moon by nixxphotography at www.freedigitalphotos.net





EMDR- rapid healing of “small t” and “big T” trauma

4 12 2013

The beginning of the end…

I recently received a new, unexpected diagnosis when I went to a skilled EMDR  therapist for help with chronic pain: Post-traumatic Stress Disorder (PTSD- DSM-IV definition and PTSD DSM-5 definition). Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for trauma developed by Francine Shapiro, PhD.  I have a less severe form of PTSD than many others who have been through horrific experiences. I have what Shapiro calls “small t” trauma. LOTS OF IT! “Big T” trauma is comprised of the things people typically think about as major causes of PTSD (see the chart below).

For me, one more thing happened this year and my resilience and coping efforts were just worn out. My already daily pain escalated. Many of us have “small t” trauma and our own unique levels of resiliency.  I grew up as a Campbell’s Condensed Soup kid (tomato was my favorite). Going into treatment I felt like a can of “Trauma Soup”- lots of trauma ingredients packed tightly into the can of mind/body/spirit!  Yet I never really considered these “small t’s” as causing my pain and other struggles. I felt as if I had these evil gremlins clinging to my mind and body, persistently resisting cognitive-behavioral efforts to make them let go of me.

It bothers me greatly that people often focus on the “big T” trauma and overlook the damaging power of “small t” trauma. Many of our clients have both types, and tragically for some, years of horrific “big T” trauma. “Small t” traumas  can also derail  quality of life and functioning. Universal trauma screening could identify many trauma survivors, change treatment plans,  and CHANGE THEIR LIVES!  Psychological trauma is a hidden epidemic. 90% of clients in public behavioral health settings have experienced trauma. – SAMHSA-HRSA Center for Integrated Health Solutions.

Below is a great chart from the TraumaAndDissociation Facebook page via www.dissociative-identity-disorder.net/wiki/Trauma  that shows some differences between “small t” and “big T” trauma. “Small t” trauma is sometimes called complex trauma and those with multiple incidents of “big T” trauma can also have complex trauma. (Link to the graphic image of this chart.) 

“Big T” Trauma

  • Major events normally seen as traumatic
  • Emotions, beliefs  & physical sensations occur in both the mind & body

Examples

-Serious accidents

-Natural disasters

-Robbery, rape and urban violence

-Major surgeries, life threatening illness

-Chronic or repetitive experiences, e.g., child abuse & neglect

-War, combat, concentration camps

*May cause PTSD in some people but not all

“Small t” Trauma

  • Overwhelming but not often seen as traumatic
  • Emotions, beliefs  & physical sensations occur in both the mind & body
  • Unprocessed traumas have a long-lasting, negative effect
  • Can cause concentration, self-esteem & emotional regulation difficulties
  • Stunts and colors later perceptions
  • Often no intrusive imagery
  • Most common in neglected/abused children
  • Become part of a negative spiral when a “Big T” trauma occurs
  • Sometimes referred to as “complex trauma”

 

What does EMDR treatment feel like?

  • I have been told that it is not possible to accurately describe what EMDR feels like to someone who has not experienced it. I agree that this is probably true- even when I give a trusted person very detailed descriptions of a session. But I wanted to try in the hope that more clinicians will consider becoming EMDR trained and  more people will seek out treatment.
  • Memory reprocessing is unique to each person. No judgments are to be made. There is structured EMDR protocol as well as strong clinical skill used. (Here are some EMDR Frequently Asked Questions.)
  • Every EMDR treatment session feels like a miracle to me. It rapidly reprocesses the gremlins of traumatic memories in my brain so that they no longer control me. And after resolving memories in an EMDR session, it is fascinating how much easier cognitive-behavioral methods now work!
  • After the basic intake information, I was asked to go back to my earliest memories and quickly give a short statement to create a log the therapist wrote of bullet points for  all of my memories. No judgments were made about what felt traumatic to me. Traumatic is a person’s perception of the experience. This list created the working plan for how we would proceed from beginning to end. Some memories are treated as individual memories, and some that have a similar theme are addressed through a cluster that enables the first, worst,  and most recent to be reprocessed and then the larger cluster is pulled together for reprocessing.
  • Before starting EMDR, I was taught to make a mental container so that I could place disruptive or unfinished memory reprocessing into the container. Using the EMDR technique, the container was “installed” so that it would stick (my word) in my brain and be there to use when needed. I practiced in session and then practiced using my container in various ways during the week so that I had mastery before I needed to use it for powerful feelings and memories.
  • To the best of my recollection, working on a single memory feels like this: I am asked to briefly describe it, notice and rate the distress level as well as the place in my body where I feel the trauma. I hold that focus and then starting using the eye moment as directed by my therapist. I can feel the memory changing in many ways during EMDR. After a brief period of doing the eye moment, we stop and I take a relaxing breath.  I share how the memory and feelings changed. No matter how crazy I feel about the way the memory is reprocessing (sometimes like watching a movie that I am writing as I sit there), there is no judgment- just attentive, compassionate focus from my therapist. We keep repeating the process- focusing on changing feelings, reassessing my distress level as we work to let my distress drop down to zero, and installing positive feelings/affirmations. Yes, there are tears but it still feels so effortless for me, so fast. I feel very relaxed and free the entire time, even when a tough memory makes me weary or takes 1 ½ sessions to complete the reprocessing. Sometimes we can do two memories in a one hour session.
  • When I arrive for the next session, my therapist always checks in to ensure that the memory work done in the last session has remained at zero distress. In one instance, more feelings bubbled up over the week and we had to work a while longer to finish resolving the memory. That is normal.
  • I am committed that I am not going to stop treatment until I get through every bit of trauma. As they say, “the way out is the way through”. I attend weekly sessions. Some people have a need or an option to go through an EMDR intensive that is usually done in a couple of days and includes multiple sessions during that time. Here are some examples of how people healed in a recent blog written by Ricky Greenwald, PsyD about the intensive EMDR treatment model.

View a client video about EMDR including the effect of PTSD on the brain (this video shows the use of EMDR equipment instead of therapist fingers for the eye movement).

Summary

Trauma is NOT about what is wrong with someone, it is about what HAPPENED to them. Needing treatment to heal and asking for it is about COURAGE, not about society’s perception that it is a weakness.

We need to remember that there two faces of trauma, “Big T” and “small t”- both deserve equal respect and a nonjudgmental approach. Evidence-based practices and a good therapeutic relationship can take you behind the human curtain and help a person heal. When trauma is not treated, people do not heal and sometimes they die. EMDR is evidence-based, fast, and life changing. We need more skilled EMDR therapists across our country, throughout the world.

I know there are people who think I should not talk about this in the way that I am in this blog…I do so because I am a social worker…I am an advocate…I am one of the many faces of PTSD…one of the many trauma warriors battling to become stronger, wiser, healthier, and happier than we ever thought possible.

Author: Lesa Fichte, LMSW, Director of Continuing Education

Photo credit: free photos at www.morguefile.com and drkathleenyoung.wordpress.com through Creative Commons Attribution

Additional Resources

EMDR & EMDR Training

EMDR International Association www.emdria.org

Trauma Institute & Child Trauma Institute (Ricky Greenwald) http://www.childtrauma.com/

EMDR Institute, Inc. (Francine Shapiro) http://www.emdr.com/francine-shapiro-phd.html

Western New York EMDR Training http://www.socialwork.buffalo.edu/conted/emdr.asp

 Trauma-Informed Care

 National Center on Trauma-Informed Care http://www.samhsa.gov/nctic/

National Child Traumatic Stress Network http://nctsnet.org/

International Society for Traumatic Stress Studies http://www.istss.org//AM/Template.cfm?Section=Home

Online Trauma-Informed Clinical Foundation Certificate Program, University at Buffalo School of Social Work Office of Continuing Education http://www.socialwork.buffalo.edu/conted/trauma-ticfc.asp

University at Buffalo School of Social Work Institute on Trauma and Trauma-Informed Care http://www.socialwork.buffalo.edu/research/ittic/

The Anna Institute www.theannainstitute.org





Therapeutic Relationships: What more do you need?

17 09 2013

Help puzzle freeditigalphotos.netID-100124223

I spent a day with Scott D. Miller, PhD, watching him training people on the power of the therapeutic relationship and how to assess client satisfaction and outcomes with performance metrics for session and outcome rating tools. Since then,  I have been fascinated by the healing power of the therapeutic relationship and its relationship to treatment. There are  evidence-based practices related to establishing therapeutic relationships at the SAMHSA Evidence-Based Therapeutic Relationships page. Yet at the same time, there needs to be a solid treatment approach. I have seen people not heal even though they had a good relationship with their therapist. And I have heard therapists say that they don’t like evidence-based practice because it takes away from the relationship and choice of the client. Perhaps fear of the unknown talking.

Good therapeutic relationships + effective treatment approaches + assessment of sessions and outcomes by the client=  the road to success and healing. And these are all essential in a trauma-informed service environment so that clients receive services within the the five-guiding principles of Trauma-Informed Care (Fallot, 2006): safety, trustworthiness, choice, collaboration, and empowerment.

Recently, trauma therapist  and founder of the Trauma Institute and Child Trauma Institute, Ricky Greenwald, PsyD, wrote a great blogpost about the  Therapeutic Relationship vs. Treatment Model. Here is an excerpt from the post that has already received 147 shares to date from his blog site.

“When I call therapists in other locations to check them out for a referral, I briefly describe the case and ask what their approach would be. Quite a number of these therapists have said something like, “I mainly focus on the relationship, since that’s where the healing comes from.” In a recent survey I saw a number of similar comments. One question focused on choice of technique in a particular context, and a number of respondents wrote some version of, “The technique is irrelevant – it’s the relationship that heals.” Based on my nonscientific sample, I suspect that this position is not uncommon among therapists.

The way it is expressed indicates that this view of the relationship’s primacy is not about psychodynamic theory – in which the therapy relationship is systematically utilized for healing. Psychodynamic people tell you that they’re psychodynamic; they’re clear about what they’re doing, and about the role of technique. No, these therapists are saying that they’ve extracted the essence of the so-called “common factors” research, and concluded that as long as they develop a good relationship with their client, everything else falls into place.

The common factors research – focusing on factors such as empathy, warmth, and positive regard, that may be common across treatment approaches – is quite important, and the centrality of common factors to therapy’s effectiveness has become ever more widely recognized and embraced (e.g., Duncan, Miller, Wampold, & Hubble, 2010). However, this valuing of the relationship over treatment approach reflects a profound misunderstanding of the common factors research.

Duncan & colleagues’ (2010) recent synthesis of the common factors research emphasized the integration and inextricability of the various factors. That is, you can’t just add more empathy or therapeutic alliance to an otherwise non-viable treatment approach and suddenly have a viable treatment. Rather, the common factors are necessarily grounded in a coherent and credible treatment model – itself a common factor – that is embraced by therapist and client. Such a treatment model serves as the foundation for the explanation of the problem, the plans for rectifying the problem, and the hope for successful change. These constitute much of the basis for the therapeutic alliance, the most important predictor of treatment success (Norcross, 2010).

Although it is heartening to see that the common factors literature has reached the practice community, it is concerning to see that it has been commonly misinterpreted in such a way that many therapists may be disregarding the importance of using a coherent treatment approach.”

via Ricky Greenwald, PsyD, Once Upon A Time… TI/CTI Blog–  Therapeutic Relationship vs. Treatment Model, August 6, 2013.

Like this post? check out our other posts on Behind the Human Curtain.

Author for the introductory paragraphs: Lesa Fichte,  LMSW, Director of Continuing Education

Photo Credit: Help Puzzle by Stuart Miles, www.freedigitalphotos.net








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