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Posts Tagged ‘abuse’


Timelines and Trigger Mapping in Healing PTSD

Posted on: by Susan

In the “old” days of psychotherapy, when I began in the 80s, abreaction or emotional release of traumatic memories was considered a goal of therapy. This idea of therapy was also made popular in powerful movies such as Goodwill Hunting.

Abreaction will happen when it happens, and it will facilitate healing. But it is not enough.

We have to live with the day-to-day realities of our history as they manifest in the present moment. With that in mind, I wanted to share two of the most helpful activities in or out of therapy for people who suffer PTSD.

The first activity is to create a timeline of events. When our PTSD results in dissociation our sense of time can get distorted. In fact, many would say that PTSD itself distorts the part of the brain responsible for the sense of time passing.

In any case, most people I see have a very poor sense of the timeline of what happened to them. Also most people I see have had more than one type of trauma. Some peoples’ lives have been one traumatic event after another. Creating a visual timeline can help us understand and digest what we have actually been through.

 Chances are, when you begin, you will not put down every event. Our brains are associative, so if you are looking at, say, accidents, you will put down accidents. But, you may forget about abuse, or you may remember one type of abuse but not another. I consider the timeline a working document in therapy, whether on paper, or just as an understanding between my client and myself.

When you record an event, you have an opportunity to look at your age at the time. A good timeline should include: event, type of event, age and any other relevant details (such as physical injury).   The timeline provides a chance to re-associate the aspects of yourself connected to your own history and is a valuable tool for your therapist. (P.S. therapists can and do become dissociative too, so this tool can help ground both of you.)

The second important activity that will really start to empower you is trigger mapping. Everyone with PTSD has triggers! They may or may not be known to you. Knowing triggers can help you and your loved ones anticipate PTSD storms and head them off.

Here is how I describe trigger mapping in my book The Trauma Tool Kit:

I recommend writing down or drawing your triggers, getting them down on paper in some form or fashion. Some triggers you will know right away; some you will have to ferret out. Triggers fall into six categories: the five senses of taste, touch, smell, sight, and hearing, plus feeling states. Let’s start with the senses, because they are the easiest. You can divide your paper into different sections reflecting each of these senses. It will help jog your memory to go through each sense modality individually. Let’s say you are working in the smell category. Ask yourself what smells really bother you. All of us have smells we do and don’t like. Generally we all like floral scents and dislike the smell of feces, but I am not talking about ordinary aversions here; I am talking about radical reactions. Nobody likes the smell of poop, but if that smell sends you into a panic or frozen numbness and dissociation, it’s a trigger. Or maybe the scent of lavender makes you want to rip someone’s head off. That’s a little unusual; write it down. Take your time working through each category. Do not attempt to do all of this work in one day! If you are in therapy, it can feel safe and reassuring to do it with your therapist. Or it may not depending again on your triggers, but find some way to do it anyway. p. 184-185

The great thing about timelines and trigger mapping is that they create a bridge of healing between the present and the past. They empower and they inform, and they are tangible.  You can also add to them and edit them as you go. It is a great joy to be able to remove a trigger off the list!

One last thing, when you do them, do them with care and beauty. Take your time. Use beautiful colors and paper. Or if you just do them in your own head give yourself the benefit of a peaceful space and time to contemplate your own history and healing.

Blessings on your journey, Sue PB



Health Care Providers: How to Welcome and Respond to Trauma Disclosure

Posted on: by Susan

TMIMy husband, a cardiologist, and I recently spoke to a group of physicians about how heart disease is caused by traumatic stress and also causes it. Afterwards, one family practice doc asked me, “I never know what to say when patients tell me their traumas.”

I realized that many doctors and therapists, for that matter, were trained in an era before abuse was acknowledged, before trauma and PTSD were common household words (in some places they still are not).

So I’ve compiled a short list of do’s and don’t’s when answering a client that discloses a disturbing history of trauma or a traumatic event.

Do:

~ Routinely administer a screening questionnaire for abuse in your intake forms. You can use the ACE questionnaire or website or come up with your own boxes to check off (e.g. history of physical abuse, sexual abuse, domestic violence, neglect, veteran etc.) Clients with a very high ACEs score will have more health problems as they age.

~ Answer with a sympathetic and simple affirming response such as:

“I’m sorry that happened to you.”
“ That is a terrible thing to have to go through.”
“You must really be suffering a lot (if the event is currently affecting the client).”

If your client’s disclosure is met with a stony or panicked silence they will leave feeling very guilty, damaged, enraged or all three. Abuse has a lot of shame associated with it. Please do not reinforce this by failing to respond appropriately.

~ Maintain eye contact with a soft gaze. Our clients often do not feel seen or like others really want to see them and their suffering. Eyes are “the windows of the soul” and the client really needs to see that you are with them in taking this great risk of disclosure. We know that people are present to us and with us when they look into our eyes.

~ Get yourself grounded in that moment. Take a deep breath and take a moment to really absorb what your client just said to you.

Some of us providers have our own trauma histories and the older we are the more likely that is. If we dissociate or ‘check out’ our client will definitely notice and probably assign the worst possible meaning to our behavior such as: “they don’t really care about me”; “they are just collecting their paycheck”; “they think I’m crazy”. Our traumatized clients already have those feelings, and they respond to any perceived confirmation of those thoughts with panic and/or rage. This panic/rage can be expressed outwardly in your office as difficult behavior or as self-harm when they go home.

~ Ask for more details – especially about how this is affecting the patient in their body right now. It is a universal truth that our clients will only tell us what we are ready to hear. They do not want to ‘injure’ us with sordid details and will often leave out important aspects of their traumas. Occasionally a client will disclose too much in a kind of verbal diarrhea manner; in those cases it is OK to gently contain the discussion and take the necessary action for that client to get help.

~ Assess for current safety and contact the correct agencies as a mandated reporter. You can never overreport elder abuse or child abuse. As a medical social work supervisor I am always surprised about how conflicted medical staff are about filing reports and how little the laws are understood and followed. The state is responsible for determining whether abuse is happening or not. Most medical providers are not trained to make those screening decisions. Hence the law that says you are a mandated reporter to file if abuse is suspected. And, yes, that means everyone on your team who has a contact with the patient. It is extremely common for abuse victims to divide up what they tell to different people. There is no way for agencies to file as a single entity. If a doctor, a nurse and a social worker talk to this person and get any kind of disclosure they ALL are legally obligated to file a report. Our clients almost never call disclosure hotlines themselves. Sometimes they don’t understand that what is happening is reportable. Child and adult lives depend on us doing our jobs. The states do a very good job of maintaining confidentiality about who said what.

~ Refer! to the appropriate provider. Have a list of trusted mental health providers in your office. Steer your client towards the Psychology Today referral website which is excellent and widely used by practitioners.

Do Not:

~ Panic. Forewarned is forearmed. Educate yourself about the types of abuse in your community and the populations you serve. If you are expecting to hear these types of disclosures (and why shouldn’t you?) your clients will have an easier time telling and you will have an easier time hearing. I have heard about some truly horrendous and damaging responses from both therapists and doctors who were not ready to hear an abuse disclosure. One damaging response can put off a patient’s healing for years or forever.

~ Promise to keep a dangerous secret. A lot of patients will ask us to keep what they tell us confidential before they want to disclose anything. Don’t paint yourself into a corner. When my patients ask me to keep their secrets, I always reply that it depends on what kind of secret they have and explain my role as a mandated reporter. That gives them more control on what they want to disclose.

~ Ignore a disclosure. Yes, I know you have less time to do more work than at any other time in your career. Working correctly with a disclosure does not have to take a great deal of time. Our patients are pretty savvy. They know we have busy schedules and lives, and they do too. The vast majority of people who disclose will not abuse the privilege. If they do, you can still be kind and containing at the same time. Or you can ask them to schedule a longer appointment soon for a full trauma assessment (something I hope to be coming soon to a medical and psychiatric clinic near you). Being busy is no excuse for being uncaring. It’s not business; it’s personal.

~ Forget to take care of yourself. Know your community population. If you are in low income, high crime area, your entire population may be filled with trauma. Taking a trauma informed approach to your practice could be the best thing you ever do for you and can avoid needless complaints and confrontations. Get therapy if you need it (and who doesn’t?). Do your own sympathetic downregulating exercises: yoga, tai chi, meditation, exercise, breathwork. The less you care for yourself and your own suffering, the less you will want to help anyone else.

There, that wasn’t so hard was it?! If you need more in-depth assistance I offer trauma-informed consultations for health care professionals, and I travel!

Be well!





Street Yoga: One of my Favorite Organizations!

Posted on: by Susan

I found Street Yoga when I was writing The Trauma Tool Kit. They are an amazing group of people working hard to bring yoga and mindfulness to at-risk youth in need. If you are inspired please click on this link.

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INSOMNIA!

Posted on: by Susan

Insomnia and PTSD go together like a mosquito bite and itching but with far worse results. Insomnia is not only a consequence of traumatic events but, left untreated, can result in such chronic medical conditions as mood disorders, chronic fatigue syndrome, and even fibromyalgia, a painful condition affecting joints and tissues throughout the body.

There are roughly 4 types of insomnia:

1) Early awakening
2) Inability to fall asleep
3) Repetitive waking throughout the sleep cycle (usually every 90 min)
4) Unsatisfactory sleep

There can be other physical or disease processes that interfere with sleep so the first step with insomnia is to get a medical exam to determine if there are any conditions, such as sleep apnea (poor breathing during sleep) that are resulting in awakening or unsatisfactory sleep (waking up tired).

With PTSD the two most common types of sleep disorder I’ve seen are the inability to fall asleep or waking approximately every 90 minutes. These are so common that if I have a patient walk in with those symptoms there is a high likelihood that they have suffered past traumatic events.

Why?

The answer is simple. REM (rapid eye movement) sleep occurs approximately every 90 minutes. In this stage of sleep the brain processes memories and emotions. That is what the brain is hardwired to do and why people normally wake up feeling refreshed.

But if the memories are too scary and overwhelming or if the conscious mind is not ready to assimilate the information a person will shut down the REM process by popping prematurely out of sleep. Similarly with sleep inhibition or the inability to fall asleep, the mind is unconsciously resisting the process of assimilation or digestion of overwhelming experiences.

For these reasons, sleep can start to feel like a very overwhelming experience and can snowball into its own traumatic situation. Insomnia breeds its own special kind of anxiety. A secondary trauma develops: the fear of not being able to sleep.

What to do?

Here are three steps to getting back to a restful night even while healing from trauma:

1) Unwind the fear about falling asleep. If you are awake use your time productively. Do some yoga postures and relaxation exercises. Or read something that is “good for you” like history, medical information or a religious text. The mind wants to shut down out of boredom after a while, just like in school. Do not read Stephen King or the latest murder mystery! Tell yourself that you will not be awake forever and allow yourself to be awake if you need to be. You can always nap tomorrow. The more anxious you are about being anxious the less chance sleep will come.

2) Develop excellent sleep hygiene. Sleep in a dark room without computers, tv’s etc. Turn off bright lights at least 2 hours before bed (yes that includes all media screens). Abstain from caffeine and sugar for 6 hours before bed. Develop a routine. Etc.

3) Most important: Start addressing your traumas! Your unconscious mind wants you to heal and will keep throwing up traumatic dreams and memories until you get the point and deal with them. Seriously. The best cure for insomnia is curing your PTSD. Find a great counselor or program and get to work! 

The alternatives to not addressing insomnia are unbearable. Pills only work for so long. If you resolve the underlying issues be they physical or psychological you will be well on your road to healing and back to the land of Bedfordshire in no time.

Sweet dreams.



Core Beliefs and PTSD

Posted on: by Susan

Last week my sweet kittie went missing. After a few very sad and anxious days, I realized that this event tapped into an outmoded deeply held belief that I did not realize I was holding. That belief is:

If I love something or someone too much, they will abandon or abuse me.

Sound familiar? It should. It is one of the most common beliefs of people raised in traumatic environments.

We all have core beliefs, about ourselves, about life, about love, about why we are suffering. These beliefs largely lay unconscious in our psyche, like a filter that colors everything we see. We don’t question these core beliefs because we do not know they are there!

People who live with PTSD have core beliefs that arise out of their traumas (and sometimes precede them). We do not choose these beliefs. In a sense they choose us. The purpose of mind, evolutionarily speaking, is to make sense out of a random set of stimuli, the environment we live in. Without mind, the world would be an inchoate mass of incoming information. Mind sorts, slots, and makes meaning of sensory input.

But it is also largely automatic and unconscious.

Our mind selects meaning similar to other messages we have been given by our families, our schools, our communities, our religions etc. Most of the time we are completely unaware of this process, just as you are unaware of your breathing right now. Think you’re aware? How many breaths have you taken in the last hour?
Right! Same with the mind. Our minds think and make meaning but we are largely unaware of the process.

So what does that mean for the person with PTSD? Well, traumatic stress ups the ante on thoughts. Our thoughts tend to be more highly charged, faster, more automatic and more intense when we are stressed. Sometimes they are helpful and help us survive. Other times not so much.

This thought that came to me: If I love something or someone too much, they will abandon or abuse me, it could have first arisen in my childhood, or maybe several lifetimes ago. But it has persisted, lurking in my mind like a malignant dustbunny. Once I became aware of the thought, I felt my body start to release. These thoughts, like shadows, melt away in the light of awareness. Do I still feel sad she is gone? Yes. But I no longer suffer from the underlying guilt and anxiety that went along with my unexamined core belief, which puts me in a much more functional position!

Now it’s your turn. What core beliefs do you have that may be holding you back from healing yourself?



TTK BREAKING NEWS

Posted on: by Susan

Hi all. Today I am pleased to tell you that one month out, the Search Inside function has been activated for The Trauma Tool Kit: Healing PTSD From the Inside Out. Quest Publishing has been quite generous with their sharing so you can begin reading now! Click on the book cover to the right of this post to go to Amazon’s site for the book. My greatest desire is that this book help you overcome your traumatic stress and PTSD. Blessings, Sue



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