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





Hoarding: the complex slide into clutter blindness

13 04 2014

room that is hoarded

Hoarding is a personal and/or professional issue for many of us. Some have a gift for viewing it compassionately. For others, especially when confronted by family members who are hoarding, it can create revulsion, horror, anger and great sadness for their lack of quality of life. Children may grow up experiencing shame and trauma from living with a caretaker who cannot stop hoarding. I have been on the verge of vomiting after trying to tackle the hoarding of a family member, and I could not go in to the house without someone with me for support.

Locally, we sometimes hear about animal hoarding in the press where someone whose love for animals and other mental health issues causes them to adopt more animals than they can manage. In areas populated by apartment and condominium complexes, there is the added risk to neighbors’ safety due to the potential for fire, mold growth and rodent/insect infestations. Some people are able to keep the hoarding inside their homes and family members, neighbors and co-workers are unaware of the situation. Others have lost control and the hoarding spreads out onto the lawn and other property. One woman even bought the house next door so she could expand her storage as she had filled her own home to capacity with hoarding. The thought of giving away a small item that most of us would consider as trash can cause significant anxiety for some individuals. My heart aches for them. It is important to remember that hoarding is not about laziness, yet this is often the judgment made.

What is hoarding?

Hoarding is a complex disorder that includes: collecting too many items (valuable as well as trash); difficulty letting items go (selling, giving away, throwing away, recycling); and disorganization (growing piles mixed with valuable items and trash with difficulty de-cluttering). There is also commonly a lack of recognition of the seriousness of the problem. Hoarding may be referred to as “compulsive hoarding”.  Clutter blindness refers to the inability to “see” and recognize the accumulation of hoarding and its impact. Animal hoarding focuses more specifically on the acquisition of animals and often includes the inability to adequately care for the animals resulting in unsafe situations for the animals and humans caring for them. DSM-5 hoarding disorders summary.

Why do people develop hoarding behavior?

This is a hard question to answer. Hoarding may co-occur with other diagnoses including Obsessive Compulsive Disorder, depression, General Anxiety Disorder, eating disorders, as well as Posttraumatic Stress Disorder. Hoarding can be a reaction to psychological trauma. When there is hoarding involved, it adds an additional level of complexity to the assessment, diagnosis and treatment plan. Sometimes hoarding is seen in several family members such as the adult child raised by a hoarder grows up and displays similar hoarding behavior.

Other aspects of hoarding development are defined by Paul Salkovskis, PhDobsessive compulsive hoarders; deprivation hoarders (have been through a period of massive deprivation) and those that Salkovskis defines as the hardest to treat – sentimental hoarders (damaged by unpredictability and possibly even neglect during childhood, possessions have become more reliable than people).

How to assess and diagnose hoarding behavior

There are tools at the International OCD Foundation website and the tools below are an excerpt from their website:

 Saving Inventory-Revised (SIR)

The Saving Inventory-Revised is a 23-item questionnaire designed to measure three features of hoarding: excessive acquisition, difficulty discarding, and clutter.

Hoarding Rating Scale (HRS)

The Hoarding Rating Scale is a 5-item semi-structured interview that can also be used as a questionnaire. The five questions include questions about clutter, difficulty discarding, excessive acquisition, distress caused by hoarding and impairment resulting from it. Initial studies suggest that a score of 14 or higher indicates a probable hoarding problem.

Clutter Image Rating (CIR)

In our work on hoarding, we’ve found that people have very different ideas about what it means to have a cluttered home. For some, a small pile of things in the corner of an otherwise well-ordered room constitutes serious clutter. For others, only when the narrow pathways make it hard to get through a room does the clutter register. To make sure we get an accurate sense of a clutter problem, we created a series of pictures of rooms in various stages of clutter – from completely clutter-free to very severely cluttered. People can just pick out the picture in each sequence comes closest to the clutter in their own living room, kitchen, and bedroom. This requires some degree of judgment because no two homes look exactly alike, and clutter can be higher in some parts of the room than others. Still, this rating works pretty well as a measure of clutter. In general, clutter that reaches the level of picture # 4 or higher impinges enough on people’s lives that we would encourage them to get help for their hoarding problem. These pictures are published in our treatment manual (Compulsive Hoarding and Acquiring: Therapist Guide, Oxford University Press) and in our self-help book (Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding, Oxford University Press).

How to treat hoarding

Hoarding is often very challenging to treat. In many areas, there are not any experts in hoarding behavior. Treatment approaches may include elements of Motivational Interviewing; Cognitive Behavioral Therapy (CBT); individual and group therapy; medication for depression, anxiety or OCD;  and trauma specific treatment for those who have a trauma history. When the person feels ready and choose to de-clutter their home, a plan for volunteers and services to assist them.

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Compulsive Hoarding Wikipedia

Select Resources

Understanding a Hoarding Disorder

Compulsive Hoarding

Hoarding as a reaction to trauma. Psychology Today

International OCD Foundation, Annual Hoarding Meeting

Anxiety and Depression Association of America Hoarding Basics

Help for Hoarders (UK)

Hoarding Inventories and Scales, International OCD Foundation

Treatment for Hoarding Disorder: Therapist Guide (Treatments That Work) by Gail Steketee, Randy O. Frost

Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding (Treatments That Work) by David Tolin, Randy O. Frost and Gail Steketee

Stuff: Compulsive Hoarding and the Meaning of Things Hardcover by Randy O. Frost  (Author), Gail Steketee

Animal hoarding FAQs, ASPCA

Animal hoarding and laws, Animal Legal and Historical Center, Michigan State University College of Law

Animal Hoarding from Wikipedia

Diogenes Syndrome, Hoarding – or Merely an Avid Collector? (thanks to Dorlee at Social Work Career Development blog)

From Dante to DSM-5: A Short History of Hoarding

Hoarding disorder as defined in the DSM-5

 





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





Trauma-Informed Medical Care? Not at my doctor’s office…

11 08 2013

meat words image courtesy of Victor Habbick at freedigitalphotos.net ZOMBIE MISTID-10076674

Yep, this topic is one of my passions: trauma-informed medical care, trauma-informed systems of medical-care, and the problem of its frequent absence in health-care settings. I have met some wonderful, compassionate medical professionals. Yet I routinely encounter those whose attitude and behavior causes patient anxiety, emotional distress, fear, and is sometimes psychologically retraumatizing. Even though patient contact may be limited to only a few minutes, it is still possible to create trauma-informed experiences that benefit the patient.

Here are some examples of what is not  trauma-informed medical care:

  • An RN case manager calls my husband after he is home from the hospital after a severe heart attack. Three times during the conversation she asks him why he had to go to the emergency room. Each time he replied that he was afraid he was going to die. (And the paramedics took him to the hospital.)  We filed a complaint and received prompt follow-up from the insurance company…but what happened in the medical provider’s system and in the nurse’s life and training  that caused such an insensitive encounter to occur?
  • At each of my frequent primary care visits, I am asked to fill out a long list of questions detailing all of my health problems. Anytime I have to discuss my medical history, I get very upset and my blood pressure rises significantly. I just prefer not to think about it, to focus on the progress, and not on the long list of medical diagnoses. Even though I explained that this process was upsetting to me, staff insisted I must comply as it was (the dreaded) policy. So I completed the awful form at home, scanned it into my computer so that each visit I just print it out, add the date and any new issue that requires attention and this does not upset me anymore. On one visit the nursing assistant who had been told before I did not want to use these forms, took me into the treatment room and then tossed a pile of these forms onto the chair where I was going to sit. She informed me that the copy I was bringing in did not have the doctor’s section on the back and I needed to use their double sided form. Big sigh…I tried not to sound belligerent as I said that my forms are scanned and printed- perhaps staff could just staple or tape their form onto the back of mine?  I handed the forms back to her and sat down. No response from her, but she never tried that again!
  • I had a recent appointment at a specialist’s office where I had been seen before but had to switch to a different doctor in the practice as mine left. The nurse said nothing but  “hello, have a seat”- no eye contact during the entire time. She then proceeded to rapidly ask me a long list of standard medical status questions. She displayed no compassion or concern for the fact that I stated my symptoms had worsened significantly in the last three months. I felt like a faceless piece of meat or at best, a shirt in a garment factory being checked by Inspector 32. This is not about the ten minutes it took to go through the medical questions that were important for the doctor to know. It is about how it was done and that it was not trauma-informed/trauma-sensitive as I was very anxious about the worsening symptoms, the impact on my quality of life, and what the future held for me.

Some people have developed Post-Traumatic Stress Disorder (PTSD) from serious health issues, near death experiences and many trauma survivors in the healthcare system frequently have additional medical, behavioral health or mental health needs. How can the healthcare system address the needs of people who have had traumatic experiences that are impacting their physical health as well as their emotional health? To start, every healthcare professional should make themselves familiar with the landmark Adverse Childhood Experiences (ACE) study of 17,000 individuals that demonstrated the strong correlation between childhood trauma/abuse and adult health problems. Watch the fourteen-minute summary video of the ACE study.

So what is Trauma-Informed Care (TIC)?

Trauma-Informed Care involves a focus on “What happened to you?” instead of “What’s wrong with you?”  While the healthcare profession typically focuses on individual diagnoses, symptoms, and treatments, I see the bigger issue as what is happening to people with medical issues, how it affects their ability to function and how it affects their quality of life. I frequently bring up the issue of quality of life with my physicians. I have never heard a medical professional talk about quality of life without me first raising the issue and bringing this perspective into the diagnosis and treatment process. TIC also encompasses the policies, services, and practices for both patients and staff. It minimizes the chance of individuals being re-traumatized by healthcare services.

The Fallot (2006) five guiding principles of Trauma-Informed Care  apply to patients and the entire organization including the employees. I elaborated on the definitions to enhance their applicability to medical settings.

1. Safety- ensure the physical and emotional safety of patients and employees. Shift to a whole person focus of “what happened to you?” instead of “what is wrong with you?” Make the physical environment welcoming, comforting, clean and safe. Value the patient’s experiences and perspectives so they feel safe. Ask them  “how are you managing to cope with these symptoms/disability/pain?” Or perhaps “how is this affecting your work and home life?”

2. Trustworthiness- provide clear and sufficiently detailed information about what patients and employees can expect and need to know; maintain appropriate professional boundaries. Return calls and requests for information consistently and in a timely manner.

3. Choice- prioritize patient and employee experiences of choice and control. Give patients options including evidence-based options so that they can make an informed decision; respond respectfully to their questions as they clarify needed information to make an informed decision. Tell them why you recommend a particular treatment, listen to their questions, and let them make an informed choice.

4. Collaboration- maximize collaboration and the sharing of power with patients and employees; it is the patient’s body so the final decision is theirs; work together with them in partnership; remember that other medical providers may be involved and multiple differences of opinions often occur that the patient must process; the provider seeks collaboration with involved other providers. Create a treatment plan together with the patient, follow it, and update it as desired by the patient through collaborative discussion. Listen to office and support staff ideas and concerns as they often have great suggestions to improve the practice and service for the patient.

5. Empowerment- recognize patient and employee strengths and skills; acknowledge patient experiences and their inner wisdom regarding their health and employee ideas regarding service provision. Patients are empowered when they are given enough information to make informed decisions. Allowing the patient to be in the “driver’s seat” may feel uncomfortable to some, but it can be very empowering to many patients.

 

Is TIC different from good customer service? Yes,  they are different although they have many similar components. A medical setting that has great customer/patient service is more likely to be trauma-informed for staff and patients, and less likely to trigger or re-traumatize a patient. However, TIC includes much more than just good customer service. In addition, there is the larger policy issue of identifying those children, youth, and adults who are trauma survivors when they enter the healthcare so that their needs can be effectively addressed with appropriate referrals and coordination of services.

So what kinds of things can make a medical or other healthcare setting trauma-informed? (Various resources are listed at the end of the blog.)

  1. Train all staff on the basics of psychological trauma and Trauma-Informed Care as well as the relationship between trauma and addiction, and the impact of childhood trauma on adult illness, disability, and death. This is a brochure on Medical Traumatic Stress: What Health Care Providers Need To Know related to pediatric illness, injury and traumatic stress from the National Child Traumatic Stress Network I was not able to find anything similar for adult trauma-informed medical care.
  2. Examine the environment, processes, forms, policies, etc. that staff and patients are exposed to and obtain input from patients through a focus group or other means to make progress toward changes to make services more trauma-informed.
  3. Ensure that any assessment tools are used as required by medical guidelines for assessing needs of trauma survivors. Have referral information readily available.
  4. Advocate as healthcare providers and patients for coordination in healthcare systems, collaboration with behavioral health and mental health providers,
  5. Practice good customer service and implement the five principles of Trauma-Informed Care.

This topic could fill a whole book, but I hope I have offered enough to give you a good start! Check out some of the resources below.

Author: Lesa Fichte, LMSW, Director of Continuing Education

Resources

Center for Pediatric Traumatic Stress, The Children’s Hospital of Philadelphia http://www.chop.edu/professionals/pediatric-traumatic-stress/about-pediatric-traumatic-stress/trauma-informed-care-for-healthcare-providers.html

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

Brochure on Medical Traumatic Stress: What Health Care Providers Need To Know related to pediatric illness, injury and traumatic stress from the National Child Traumatic Stress Network http://www.chop.edu/export/download/pdfs/articles/traumatic-stress-pdf-cpts-mtsbrochure.pdf

Medical Trauma from the National Child Traumatic Stress Network http://www.nctsn.org/trauma-types/medical-trauma

The Adverse Childhood Experiences Study http://acestudy.org/ and http://www.cdc.gov/ace/index.htm

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study http://www.ajpm-online.net/article/PIIS0749379798000178/abstract

Using Trauma Theory to Design Service Systems: New Directions for Mental Health Services,  Maxine Harris and Roger D. Fallot (2001) http://www.amazon.com/Trauma-Theory-Design-Service-Systems/dp/078791438X/ref=sr_1_1?ie=UTF8&qid=1376250212&sr=8-1&keywords=harris+and+fallot

Trauma-Informed Services: A Self-Assessment and Planning Protocol, Community Connections: Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D. (March, 2006) http://smchealth.org/sites/default/files/docs/tisapprotocol.pdf

International Society for Traumatic Stress Studies http://www.istss.org/Home.htm

Traumatic Stress: An Overview, American Academy of Experts in Traumatic Stress http://www.aaets.org/arts/art1.htm

Article: Some Medical Trauma Might Induce Later PTSD http://www.goodtherapy.org/blog/some-medical-trauma-might-induce-later-ptsd-0716132

How to Provide Good Customer Service in a Health Care Setting http://www.ehow.com/how_7372599_provide-service-health-care-setting.html

Customer Service in Health Care Optimizing Your Patient’s Experience by Karen A. Meek http://pacificmedicalcenters.org/images/uploads/KCMS_Customer_Service_in_Healthcare.pdf

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

Trauma-Informed Care Information & Resources, University at Buffalo School of Social Work http://www.socialwork.buffalo.edu/facstaff/tic_resources.asp

Video from the Cleveland Clinic on ‘Empathy: The Human Connection to Patient Care’. Provides great perspective on remembering that you don’t know what a person is experiencing or feeling inside; we all have struggles. https://www.youtube.com/watch?v=cDDWvj_q-o8&feature=share

University at Buffalo School of Social Work Trauma-Informed and Human Rights MSW Curriculum http://www.socialwork.buffalo.edu/about/tihr.asp

Trauma-Informed Certificate Programs and workshops from the University at Buffalo School of Social Work Office of Continuing Education http://www.socialwork.buffalo.edu/conted/trauma.asp

Photo credit: image courtesy of Victor Habbick at www.freedigitalphotos.net








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