Trauma & Attachment Therapy

Why We Do Trauma Therapy

Here is the last paragraph of the Introduction to Trauma Treatments Handbook, Protocols Across the Spectrum. You're seeing it before the publishers do. Before I send it in, do you have anything to add about why we do this work? I'll publish what you write, unless it's spam.

 

As trauma therapists, we are privileged to use all of our selves to help people heal from deep wounds. We connect deeply, from the heart, all day long. We use our detective brains to puzzle out what is happening with our clients and what do about it. We enjoy helping the grateful single-trauma survivors get quickly back to their lives. We dig deep into our skills while slowly and carefully helping our most dissociative clients into their new, healed selves. We continually learn new skills from the innovators in our field and in innovative collaboration with our clients. We hang out with colleagues who love their work and support ours. Throughout each therapy we are delighted to hear, “I finally know it’s over!” “I feel like ‘me’ again!” “It wasn’t my fault, I was a little kid when that happened.” “I’ve got my body back!” “I can have sex again.” “I didn’t have one nightmare all week!” “Thank you for letting me get completely here and now!” “I’ve got my life back!”

 

Kathy Steele: Neurobiology of DID, on Science Friday

Kathy Steele, cocreator of the Structural Dissociation Theory, patiently defends the existence of Dissociative Identity Disorder to Ira Flatow and Numan Gharaibeh (a clueless psychiatrist) on NPR's Science Friday. Worth a listen: http://www.sciencefriday.com/program/archives/200911133 

I've run into this blindness before, mostly in analytically trained psychiatrists, despite all evidence.

NYT's article and video about military women with PTSD.

Video of military woman with PTSD: Video

Article about military women with PTSD: Article

Check out Damien Cave's article in today's New York Times. Women are less likely to be granted disability on the grounds that they weren't in combat, even though they are seeing plenty of action in Iraq. Unrecognized, they feel shame about having the flashbacks and aggression that characterized PTSD and are even less likely to seek treatment than male soldiers.

 

Self Care for Trauma Therapists

As trauma therapists, we are privileged to watch our clients’ trauma fade from terrible, here-and-now experiences to mere memories; their dissociation shift to integrated presence, and their pain disappear. We are also privy to the gut-wrenching details of rape, accidents, war, and story after story of child abuse, domestic violence, and horrible neglect. The more terrible the abuse and the more dissociated the clients, the more they project the actual emotions of their trauma into us. Some therapists become grim. Some avoid complex trauma clients. Some help their clients avoid expressing affect in the sessions. Some burn out and leave the profession. Here are some ways to keep yourself whole while doing this important work.

1.   Do your own work. If you’re not able to tolerate your own history and your current affect, you won’t be able to tolerate the despair, rage, shame, and grief that move through many trauma survivors.

2.   Learn mindfulness. Meditate, do yoga, do chi gong, do breathing exercises. It will help you “stay in the chair” while witnessing whatever is there to see. Learn to breathe and ground yourself while being with anything.

3.   Know yourself. If you start a session in a state of equilibrium, and you start feeling rage or exhaustion in the session, guess that it may be the client’s rage or dissociation. If you then say “What are you feeling right now? There’s something in the room.” The client is likely to say, “Oh, I’m angry, I guess it’s about X.” or “Oh, I was just spacing out.” When you know where you are, you’ll know when you are being drawn into someone else’s experience and use it for their benefit.

4.   Know the signs of burn out:

a.   You aren’t excited to go to work.

b.   You talk only about work and have no other interests.

c.    You treat everyone on earth like a client.

d.   You dream about clients, all the time.

e.    You’re angry at clients for being the way they are.

f.     You feel shame for your human limitations.

g.   You have vicarious PTSD: flashbacks, anxiety, depression, avoidance around client material.

h.   You want to drink, gamble, or otherwise dissociate after work.

5.   Get support.

a.   Join a supportive consultation group. (Not just about the technique, but about you, too. And no shaming allowed.)

b.   You might get individual consultation for the most troubling cases. As a consultant, I’m going step-by-step with a few consultees with their most fragile, barely tractable cases. It’s good for the therapists and good for the clients.

c.    Increase your therapeutic arsenal. If what you’re doing isn’t working, find something else that does.

d.   Do your own work. Hire a good trauma therapist who can help you clear your vicarious trauma.

6.   Develop other interests that have nothing to do with therapy. Make sure some of them involve unmitigated joy.

7.   Do things that bring you into your body: Run, stretch, work out, dance, do yoga.

8.   If you have any control over your schedule, limit the number of the most complex, dissociated, abused, unstable clients. And don’t put them all on one day.

9.   You will probably learn your tolerance the way most of us do, by exceeding it. Once you know, keep your own boundaries. Follow the Platinum Rule: “Fill your own cup first, then give away what’s left over.” And another rule, “To Thine Own Self Be Nice.” Trauma is compelling, but don’t let it run your entire life.

10.  Watch out for grandiosity. You can’t fix everything. Know your limits.

11.  If you have a spiritual practice, use it to support your work. Ask whatever higher power you have for help when stuck.

 

 

Update on Health Care Reform from a Mental Health Lobbyist

From Laura W. Groshong, LICSW, Director, Government Relations, Clinical Social Work Association:

I have just returned from three days of lobbying in Washington DC for the Clinical Social Work Association and have some new ideas of what the President and Congress (the five committees and one informal "Group of Six") are doing to develop a health care reform plan.
 
I think the President is trying to pull together at least four major political groups in Congress (Democratic progressives, 'Blue Dog' conservative Democrats, Republican conservatives, Republican moderates), which are being influenced primarily by PHarma, the AMA/other clinical groups, insurers, hospitals, and AARP/other consumer groups. Any of the political groups could theoretically sink health care reform.  Mental health groups/associations (57) are working well together in the Mental Health Liaison Group, but don't have the kind of influence that the AMA does.  We are working with the AMA on several issues where we have common cause, e.g., stop the proposed 21% Medicare cut to providers scheduled to go into effect in 2010, keep the "evidence based practice" provisions from taking clinical decisions out of our hands (even though this concept started in medicine, and has increasingly become the de facto way that insurers operate), expansion of care to include the uninsured, etc.
As a clinician and lobbyist, I think there is rarely a time when you can accomplish everything you want, in working with patients or in legislation, no matter how strongly you feel.  I think President Obama, Speaker Pelosi, and Majority Leader Reid are trying to deal with the reality that the conflicting interests here will not allow wholesale reform of the health care delivery system or expansion of the kind that would be most humane.
 
Most successful legislation in my 12 years of experience is incremental and works pretty well because most issues do not arouse the conflicting passions that health care is right now.  I think it has become the lightening rod for other sources of anger and anxiety, not the least of which is job loss and income reduction in general. This is unfortunate because it could stop our getting some improvements in health care delivery and coverage altogether.
 
Much as some legislators and interest groups have framed this as an all or nothing situation, it does not have to be.  The HELP draft bill, HR 3200 in the House and the Baucus/Group of Six bill draft all contain several pilot projects which would give us a chance to see what works best in containing costs, the driving force behind any health care reform. 
 
The legislator working the hardest to make sure that any bill has a strong mental health and substance abuse benefit is Rep. Patrick Kennedy (D-RI), with some help from  Rep. Barney Frank (D-MA).  Neither House wants to determine what the basic benefits package should look like at this time.  A new Federal oversight body may be created to do this, the Department of Health and Human Services could be charged with developing the package, or Congress could eventually decide to do it themselves.
 
Here's the time frame as I see it.  Things are on hold until the Baucus bill comes out on Tuesday or Wednesday.  After amendments are considered by the Finance Committee (the 'mark up'), the bill will be passed by the Finance Committee. Then the full Senate will consider the HELP bill and the Finance Committee bill and reconcile them.  This will influence the bill, HR 3200, which has been passed out of three committees in the House, but has not passed the whole House of Representatives.  The Majority Leader intends to pass a bill by mid-October; the President has asked for a bill to sign before Thanksgiving, so the two bills which emerge would have to go to conference committee as soon as possible to be integrated.  Again, the Baucus bill is seen as the most likely framework for a bill that could be passed by both Houses.  

A word about the "public option", or a government health plan to cover the uninsured who cannot find insurance that they can afford.  Though this is a popular concept for liberal representatives in particular, and some clinical groups, keep in mind that the way it is being developed is to tie payment to Medicare rates, possibly plus 5-10%.  That could be a reimbursement decrease for some mental health clinicians.  It appears that the public option will not be part of the final bill but I wanted you to be aware of the financial piece which is not widely known.
 
I hope this is helpful in understanding the incredibly complex process taking place in Congress which will affect all mental health and medical clinicians, in some way.  Please let me know if you have any questions.
 
 
Laura W. Groshong, LICSW, Director, Government Relations
Clinical Social Work Association

Lessons Learned While Writing A Book for Psychotherapists

I'm 13 chapters into writing Trauma Treatments Handbook, Across the Spectrum. Here's the advice I'd give anyone doing the same thing:

• Get a second screen for your computer. Keep the reference page, internet search materials, etc. open on the second screen. It will save you days of searching for the right open file.
• Start the reference list on the first day of writing. Write the reference first, then refer to it in the text. Do it on a separate page.
• Figure out who you're writing for and address the book to them. I have a range of imaginary readers, from clueless, but bright, grad students to informed therapists. I try to keep it simple enough for the students and entertaining and interesting for the rest.
• Use your own voice and use active voice. It's hard to read academese. Don't try to impress anyone with how much you know. It's not the point. Make it accessible.

• Don't worry about people hating it. Some will. I'm writing a book that will piss off every true believer, by showing the usefulness of every trauma technique that I know about, and by talking about the shortcomings, too.

• Take some time to only write. I just took two weeks off, writing about 5 hours a day. I was able to hold all the chapters in my mind and let the obsession take over me: waking at 3 and 5 a.m. to scribble notes. Up at 6:30 with my brain ready to go, moving things from one chapter to another. I finished 4 chapters, including one very long one. My brain needed time to nail the structure of the book.

• Make a list of acronyms to put at the end of the book. I've wanted every therapy book to have them. Put them on the list the minute they pop up in the text. I'm up to 3 full, double-spaced, pages of acronyms and 9 pages of references, so far.

• Talk over difficulties with anyone who is around. Everytime I began to tell my husband about a quandry, it solved itself before I was done explaining it.

• Use the thesarus on dictionary.com

• Read many sources.

• Share milestones with your friends, virtual or in person. Let your publisher know too. They worry about books not being on time.

• If you don't know something that you want to include, ask everyone. I still don't know where Kluft said, "The first integration, isn't." Do you? Or was it Kluft?

• Enjoy the process of writing. Let the "alter" that writes take over and type. It's easier than torturing yourself over every word.

• Don't fall in love with your words. Reread. Edit. Reread. Edit. Reread. Edit. But don't worry. Your brain knows. Trust it. And trust that there will be mistakes in y our book. Despite you, your professional copy-editor and your friends.

• Back up everything to an external hard drive, every day. Every done chapter, send an email with attachments of all chapters to a few friends who don't live in your town and ask them to put the attachments on their hard drive. If you have gmail, as I do, you can send the attachments to yourself and they'll live in the gmail "cloud" of servers. Losing a book is a terrible thing. BACK IT UP!

• Exercise, get massage, socialize. You live in a body with needs. Take care of yourself.

• A book is a great excuse to neglect your blog. Sorry everyone!

Mentally Ill Offenders Strain Juvenile Justice System

This distressing article, http://www.nytimes.com/2009/08/10/us/10juvenile.html?_r=1&pagewanted=all by Solomon Moore in today's New York Times shows us how the mental health system in most of the country is failing teenagers. Kids who need medication, psychotherapy, and structure act out until they end up in detention, often physically and sexually abused by both fellow inmates and staff, with little or no treatment. I worked with one of these guys in a day treatment program. The PTSD was the worst part of his disorder. With what little we knew about trauma at the time, we got him through it, and out of the system. 

In 1983, I saw Ronald's Reagan's gutting of the community mental health system gut treatment for mentally ill adults. I ran a day treatment program that actually worked. We got most of our clients, except the most psychotic, main-streamed into jobs and schools. When Reagan cut the funding medicaid funding, our program closed, and many of our clients who had been maintained on 3 hours of group, 3 times a week, had no where to go. Some lost their housing. Some lost their lives.

If we truly get health care for all and it includes mental health care for all, this may change. I hope so for the lives of all the sick and mentally ill people in our still wealthy country.

Narcolepsy and EMDR Processing

A client has given me permission to post about her situation: the effects of Provigil, Prozac, and time on trauma processing:

 

Round 1, 15 years ago: She was bright, effusive, and had the odd habits of jerking her head up to look around and writing down everything I said. We worked for eight months using EMDR to clear the PTSD from the physically and emotionally abusive marriage that she had escaped 17 years before. She seemed dissociative, but in a strange way, staring off, then going to the head jerk. The EMDR worked, the flashbacks stopped, the client, satisfied, went off.

 

Round 2, 10 years ago: After her narcolepsy diagnosis, she started taking Provigil. A few days later, the flashbacks from the abuse began again, and she returned to therapy. We went after the abuse, in greater depth as more details arose. Again, we cleared all we could find, and she left therapy feeling good.

 

Rounds 3 – 5: I saw the client through the illness and death of a sweet boyfriend, and various stressful work situations. Then as she became more constitutionally anxious, then obsessive, which became manageable when she started Prozac.

 

Round 6: last week: Planning her 45^th high school reunion, to which her abusive ex-husband had been invited, brought up the next round of distress over the marital abuse. SUD 10, when she thought of him. She processed through fear and rage, bringing up memories that had not arisen in rounds 1 or 2. She left, after a 60 minute session, feeling safe, calm, and able to ignore him, if he came to her reunion.

 

She and I think that whether or not her narcolepsy was a dissociative response, the Provigil allowed her brain to stay on task with the trauma processing, and that the Prozac with the Provigil keeps even more of her brain online and on task in trauma processing. She and I would love to hear if other people have had similar reactions with these medications affecting the depth of trauma processing.

Avoidance, AIDS Dementia, and Chosen Families

Last Wednesday I flew down to Fresno, CA, and flew back up with an old friend who, after battling AIDS for 25 years, is losing the fight. R''s brother and a few other friends and I have been managing his care up in Seattle for the last week.

R is one of my favorite flavors of people, a skinny nervous person, smart, funny, charming, talented, and relational. He has also had OCD since I met him in 1980. The OCD, related to a bipolar diagnosis, manifested in several ways, eating disorders, an inability to get out of the house without carrying half his belongings with him (the bag-lady syndrome "what if I need something"), and extreme indecision. The OCD also carried avoidance behaviors. R. avoided conflict, asking for what he wanted, and anti-retrovirals. He would get busy controlling the minutiae of his life while avoiding the big issues. In the last few years, he would worry incessantly about his belongings in storage units, while not chasing down the health care that he needed. Several of his Seattle friends offered to fly down to help him. He couldn't accept their offers because his appearance (another obsession) wasn't up to par, his apartment wasn't clean, and he would have to take care of them (another compulsion.)

Two months ago, R got pneumonia and began to show signs of dementia. His California social worker, Frida, and I talked him through getting on an ambulance to the Emergency Room. We both thought for sure that he would be admitted, but he was cut loose with some heavy-duty antibiotics and sent home. After a few weeks of daily calls by the Seattle support group, he had managed to take his pills daily, but was obviously losing his mind. A month ago his brother flew down and took over. 10 days later his brother's boyfriend drove down to help. R. was emaciated, covered with KS, and had about 2 minutes of short term memory. He didn't know where his own bathroom was. He didn't finish a meal without constant reminders. Last week I flew down and flew up with him. He was hospitalized at the best AIDS hospital in town and will go to Bailey-Boushay, a state of the art AIDS care facility, with loving staff and loving volunteers and really good art.

My feelings are extremely mixed. My lovely, vain friend, has a wasted body and a wasted mind. He's in pain much of the time. I'm grieving. I'm sad. But we have him now, he won't die alone, and he's in the best possible care, so I'm relieved, too. I'm also, clinically, fascinated by the dementia process (when I'm not frustrated by it or laughing.) R. can remember people and activities from 30 years ago. He can charm nearly every nurse and doctor who comes in the room. He remembers, at this point, all the people who love him and whom he loves. His right brain is working pretty well. His left brain doesn't tell him where he is, anything that happened in the last 6 weeks, what day or time of day it is, or the name of the person in front of him whose name he just asked. He is often sweet and charming. The more confused he is the snarkier he gets. He is very sarcastic, especially with his long-suffering brother. R. confabulates what he doesn't know. His brain makes up stories to fill the holes in his memory. Some are quiet elaborate. I haven't seen R in 8 years, nor has he been on a plane in that time, but evidently we've been on several long trips together. His brain told him that he has an apartment in a neighborhood of Seattle, not Fresno, and he wanted me to take him out of the hospital and take him home. Much of the time he thinks he's in Fresno, despite the view of Puget Sound out the window. His friend, Joe, says, "is that Fresno out the window?" and R. replies, "Oh, we're in Seattle." R., the compulsive care-giver, asks for back and foot rubs, tells the doctors that he wants us in the room to supply information that he won't remember, and has allowed us to talk him into many medical procedures. The right brain relational trust is working, even though the left brain thought process is not. His sentences are complete. His syntax is perfect. He knows his social security number. And he doesn't know who visited him or what vile procedure they just did or that his body is wasted or that he has AIDS. The KS constantly suprises him. (Advanced Kaposi's Sarcoma looks like an archipelago of red, mountainous islands everywhere but his feet, hands, and face. Sometimes it hurts like hell, sometimes it itches, sometimes it's hot to touch.) He asks, "Why am I so weak? Why do I hurt?"  "Honey, you have advanced AIDS." "When did that happen?"

Back in the 80's, I lost about a hundred friends, clients, mentors, colleagues, and neighbors to AIDS. I started the AIDS Mental Health Network, which gave free training to therapists about psychosocial issues, safe sex, dying, resources, anything we needed to know. It was before the AIDS agencies arose and we were flailing to find information and the skills we needed to take care of all these dying young men. Back then we created care committees: chosen families of caregivers that ran errands, cleaned houses, did pharmacy runs, took the person to the doctor, and generally hung out. There was no internet, so we communicated by phone, and sometimes by a log at the PWA's (person w/ AIDS) house. R. has an AIDS nursing home to go to, the Lifelong AIDS Alliance, and a group of about 5 people, including his brother, who are the support team. In the 80's, PWA's died within 16 months. R. has lived with AIDS for 25 years, at least, and is in the last stages with good medical and social support.

Schizophrenia May Be Linked To Immune System

Jon Hamilton reports on NPR about three research studies showing that schizophrenia, while having a definite genetic component may need a viral kicker to turn on the appropiate genes in utero. An old Danish twin study that I read about 25 years ago, and can't cite, shows a link between birth trauma, in genetically susceptible people, and schizophrenia. I guess you have to have the genes, then have something else needs to happen.

Here's the link: http://www.npr.org/templates/story/story.php?storyId=106151437