shea alexander, lpc-s monica urbaniak,...
TRANSCRIPT
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Shea Alexander, LPC-S Monica Urbaniak, LMFT-S
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Point at which the survivor engages with the advocate/agency ◦ Hospital
◦ Crisis Hotline
◦ Court Accompaniment Request
◦ Speaking Event/Training Session
◦ Outreach Events
◦ Other
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RAINN
TAASA
Local Agencies
Local Mental health practitioners
Law Enforcement
Hospital ER
Religious/Spiritual Communities
Other clients
Internet searches
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Intervention Refresher
Challenges
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What is a Crisis State?
A feeling response to a situation or event of such intensity that an individual’s effective coping methods are inadequate
those in crisis often feel hopeless/helpless and often experience confusion and perceptual distortion
crisis is time-limited and must be resolved in some way
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Reduce immediate impact of crisis
Understand precipitating circumstances
Help person access healthy coping skills, capitalizing on strengths, support systems and community resources
Help person move beyond the crisis to a positive and productive state
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Establish Rapport
Isolate the Problem
Explore Options
Encourage Action
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Step 1: Establish Rapport
LISTEN
Identify emotions (stated & implied)
◦ Reflect what you hear
◦ If client is very upset, allow client to express emotion
Accept client’s right to feel that way
Acknowledge that client is reaching out and taking the first step
Express warmth, concern and be genuine
Step 2: Isolate Problem Help client to identify the
immediate crisis
May be multiple problems – Assist client in identifying most prominent issue
Reflect, paraphrase, summarize
Identify which parts client has control over/can do something about
Explore what is currently going on – look at the big picture
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Step 3: Explore Options What has already been tried?
DO NOT give advice
Help client to identify viable options
◦ Allow client to take the lead in coming up with options
◦ Help client to process consequences of each options
Provide information and referral if needed
Allow client to choose which option is best for them and their situation
NOTE: Sometimes there is no “solution.” Understand that you have helped the client by just being there and listening.
Step 4: Encourage Action Help client to identify firm plan
Help client to identify steps
they can take
Acknowledge fear and tentativeness
Show support – client is reaching out
Help client identify additional resources – support systems, coping skills, etc.
Offer additional support if needed
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Group brainstorm
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Overview – Brain/Trauma
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Importance of understanding how the brain functions during and post traumatic experiences
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Biochemical:
◦ Flow of adrenaline, noradrenaline (epinephrine and norepinephrine)
◦ Release of Glucocorticoids/Cortisol
◦ Oxytocin, Vasopressin and Opioids
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Physical
Psychological
Relational
Cognitive
Behavior
Spiritual
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Newer Intervention Models
Mindfulness
Cognitive Based Strategies
Behavior Focused Strategies
Systemic/Ecological Approach
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Mindfulness
Rapid Resolution Therapy, Jon Connelly (based on neurobiology and trauma-informed treatment; utilizes hypnosis)
Brainspotting, David Grant & Liza Schwartz
Somatic Experiencing (SE), Peter Levine
Emotional Transformation Therapy (ETT), Stephen Vazquez
Modern Transactional Analysis (TA)
Stage-By-Dimension, Lebowitz, Harvey and Herman
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Transactional Analysis is a contractual Psychotherapy. Prominent use of contracts with clear goals, the attention to cognitive distortions, originating from ego states and focus on who is present in the interaction.
Mindfulness is as simple as becoming aware of your here and now experience, both internally and in the external world around you.
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Example - Kornfield Method: Practice mindfulness at the beginning of the session. Have the person sit quietly when they come in. Suggest they come five to ten minutes earlier. Sit, feel their breath and notice what’s happening
inside. (If they can’t come early and sit in waiting room, ask
them to sit quietly for five minutes at the beginning of the session.)
Ask them to let all the chatter to die down. Ask them to get more in touch with what really is
weighing on their heart or what they are really longing for.
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Suggested language: ◦ Before we deal with the difficulties you have, let’s
become present for what’s here now ... without any story.
◦ How is your body? What does it feel like now? ◦ Feel your feet on the floor. Experience your breath ◦ Focus on which emotions are present … without any
story. ◦ What state are you in – open, closed, sad, happy?
After sitting quietly and checking in with their body, their breath, and the emotions that are there we can begin to dialogue. ◦ Clinician can inquire, “How does that feel? What is
connected to that?”
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Based on the concept:
◦ Perceptions _____lead______ to Feelings _____lead ____ to Response
◦ (Lack of Control__________Helplessness___________Fear & Anxiety)
Designed to reduce psychological distress; helping client to identify and change dysfunctional thoughts and beliefs.
Using cognitive restructuring techniques - target dysfunctional patterns of thinking that lead to exaggerated emotional responses; replace it with more effective ways of thinking.
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Classical Conditioning (Understanding the impact)
Actual Injury/Harm________Elicits______________Fear & Anxiety
Threat (Unconditional Stimuli)________________________(Unconditional Response) When triggered: Traumatic Experience____________Evokes_____________Fear & Anxiety (sounds, smells, tactile, other)
(Conditional Stimuli)_________________________(Conditional Response)
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Systematic Desensitization In Vivo Exposure Imaginal Progressive Muscle Relaxation Breathing Control techniques Guided Imagery Role Play
1. Therapist models first. 2. Start with more innocuous or benign scenarios and proceed to more fear and
anxiety producing one as therapist is assessing client’s readiness. 3. Therapists points out areas needing improvement. 4. Therapist positively reinforces appropriate responses
Covert Modeling - Imaginal role playing, visualizing confronting the
fear and anxiety provoking situation/element, successfully using appropriate and adaptive behavior.
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Acceptance and Commitment Therapy (ACT) (Hayes et al) – A collection of exercises, metaphors and other techniques to promote
accepting psychological distress as a normal process vs. a pathological one. It centers on facilitating client’s acceptance of their history, emotions and thought while continuing in behavioral change.
(See: Acceptance and Commitment Therapy for Anxiety Disorders: A Practitioner's
Treatment Guide to Using Mindfulness, Acceptance, and Values-Based Behavior Change Strategies by Georg H. Eifert and John P. Forsyth)
Strategies based on the Adaptation Theory (McCann, Sackheim and
Abrahamson) – trauma survivors, in order to make sense of their experience, which may be inconsistent with their existing beliefs and understanding of the world, seem to adapt in two ways: Assimilate or Accommodate
The authors believe victimization could affect five major areas in maladaptive ways: Safety, Trust, Power, Esteem, and Intimacy.
Use of Mindfulness practices in ACT- Georg Eifert, PhD and John
Forsyth, PhD – A practitioner’s treatment guide to using Mindfulness, Acceptance and Values-Based Behavior Change Strategies
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Assessment Phase/Stage I:
Individual & Family Crisis Intervention
Evaluate survivor’s mental, emotional and physical health
Assess environmental factors
Ensure survivor’s SAFETY
Assess survivor’s support system
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Establish rapport (Relational): ◦ Acceptance ◦ Normalization ◦ Understanding of cultural, personal, and
family & social values ◦ Empathic positive unconditional regard
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Provide psycho-education
Help establish support network/support group
Help client to differentiate appro. vs inappro. self-disclosure of trauma experience
Provide a safe, confidential environment for client’s self-disclosure
Help client to learn how to communicate feelings more effectively
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Facilitating survivor’s control of: ◦ Physical Environment: Establish SAFE living situation
with adequate attention to survival needs (work, money, etc.)
◦ Physical/Emotional Health: Includes attention to basic health needs, regulation of bodily functions such as eating, sleeping, exercise and control of self-destructive behaviors, learning mindfulness.
◦ Social Environment: Educating survivor regarding SAFE relationships
◦ Reminder primary focus is SAFETY
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Trauma experience:
Provide insight
Help develop or strengthen coping skills
Utilize variety of counseling techniques (Active listening, Modeling, CBT, CPT, TA, Gestalt, EMDR, ETT, Brainspotting, etc)
Work on trauma experience (Trauma processing not trauma-evoking)
Focus shifts from safety alone to safe exploration of traumatic experience(s).
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Uncovering of trauma needs to proceed in small steps.
Pacing and timing is adjusted to the survivor’s “window of tolerance”, so that intervention represents a mastery experience vs. a symbolic reenactment of the trauma.
Expand survivor’s “window of tolerance” gradually, ensuring safety following session and ability to manage symptoms.
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This process may involve a period of intense grief and mourning, during which the survivor contemplates the full extent of his/her losses, both internal and external (changes in identity and the new normal).
The risk of major depressive episode is high at this point.
The survivor needs to be sustained by the therapeutic alliance, peer support and hope of restoring and building new non-exploitive relationships.
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This phase also includes a new level of meaning-making and transformation of traumatic experiences, sometimes taking the form of a survivor mission. Making sense of suffering (ACT, Logotherapy, Mindfulness)
Note - Not all survivors go through all three phases. Many enter ready to work in Phase II. Many stop after the initial phase and return to work on the other many years later.
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This recovery phase involves the active pursuit of social reconnection.
In the process of establishing mutual, non-exploitative peer relationships with friends, family and spouses/partners, the survivor often reassesses and renegotiates long-standing relationships. Addressing issues of boundaries, and limits, perhaps for the first time.
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Group Brainstorm
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Katie
Tammy
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White female, age 22, single, upper middle class
SA by acquaintance while away at college
Moved back in with parents
Recent loss of employment and at risk for dismissal from school (absenteeism and grades)
Symptoms include: poor eating habits (vacillating between binging and starving herself), sleep disturbance, nightmares
Parents do not know about SA, are puzzled by daughter’s bx., angry and disappointed
Marginal support from a college friend
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Black female, single, age 42
Hx. of childhood emotional abuse and neglect (by mother), absent father, sexual abuse as a child (by neighbor) SA as teen (by classmate), recent sexual assault (“date”)
Married and divorced two times; has an adult child who lives in another state
Symptoms include: anxiety and intermittent suicidal ideation, difficulty in developing/maintaining close relationships, socially isolated, impairment in work functioning, self-injurious bx (cutting, binge eating), flashback, nightmares
Using ETOH as tool for coping
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Which model of treatment/intervention techniques might be effective for the client in the case example?
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When to ask for help
References
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It’s the right thing to do to ask for help at any time!
Orange flags: ◦ Feeling panicky, scared or very emotional inside
◦ Feeling as if you should have an answer
◦ A strong emotional reaction after you have left the client
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Principles of Trauma Therapy, John Briere, Ph.D. & Catherine Scott, M.D.
The Assessment and Treatment of Complex PTSD, Bessel A. van der Kolk, M.D.
The Trauma of Sexual Assault, Edited by Jenny Petrak and Barbara Hedge
Relational Transactional Analysis, Principles in Practice, Edited by Heather Fowlie and Charlotte Sills
Acceptance and Commitment Therapy for Anxiety Disorders– A practitioner’s treatment guide to using Mindfulness, Acceptance and Values-Based Behavior Change Strategies, Georg Eifert, PhD and John Forsyth, PhD
Buddha’s Brain: The Practical Neuroscience of Happiness, Love, Wisdom, Rick Hanson
Jack Kornfield, The National Institute for the Clinical Application of Behavioral Medicine www.nicabm.com
Shea Alexander, LPC-S