Handouts 2

Trauma Recovery Roadmap

A Somatic Resiliency Approach

Ideas from:

Ron Kurtz, PhD (The Hakomi Method)

Peter Levine, PhD (Somatic Experiencing)

Pat Ogden, PhD (Sensorimotor Psychotherapy)

Maya Youngblood, LLCP, SEP (Private practice)

David Kerr, SEP (Somatic Experiencing colleague)

Stephen Porges, PhD (The Polyagal Theory)

Julian Thayer, PhD (The Neurovisceral Integration Model)

Babette Rothschild, MSW (The Body Remembers)

Moriah Stillwater, SEP (Private practice)

I like to note these to emphasize both that many of my ideas are not original with me but are a synthesis of the work of others and my own practice experiences, as well as to indicate the Somatic Resiliency approach has a great deal of evidence.

The concepts, principles, strategies, and techniques in recovery from psychological trauma are simple. We need the knowledge of these things and the willingness to practice regularly what we learn. This Roadmap is meant to be both a guide and a reference for you.

Areas to cover:

Definitions of psychological trauma

Post-Traumatic Stress Disorder and complex developmental trauma

The “Big Three” long term effects of developmental trauma

The three main components of trauma recovery

Principles of trauma recovery

Topics to learn

Trauma recovery treatments

Helpful attitudes to develop

Misunderstandings in trauma recovery

Basic trauma recovery skills

Real time feedback to therapists

Recommended books

Definitions: We can define psychological trauma in two ways.

Anything that overwhelms our capacity to cope and threatens our survival, either physically or psychologically is psychological trauma.

Trauma comes from the ancient Greek word “trauma” which means wound. Anything that wounds our hearts, souls, or spirits is psychological trauma.

This means:

Everyone experiences psychological trauma, some more threats to survival and some more heart wounds but to be human in this world is to suffer from trauma and loss.

Trauma is not a disease. The term Post- Traumatic Stress Disorder is inaccurate. It implies we have a disease, a disorder, an illness, a sickness, that something is wrong with us, we need to be fixed etc. This is not the case. What we have is a normal nervous system response to traumatic circumstances from which we fail to bounce back from or heal.

Therefore, everyone can recover, no matter how early the trauma or how old we are when we start the recovery process. We are not treating a disease process, but restoring a nervous system to better regulation and health.

There are two main types of trauma – event trauma and developmental/chronic relational trauma.

Event trauma is something that happens to us such as a fall, an injury, a motor vehicle accident, a physical or sexual assault, a medical complication, the sudden loss of a loved one, a combat situation, a natural disaster, situations encountered by law enforcement officers and other first responders, etc.

Developmental/chronic relational trauma, often referred to as childhood trauma, complex developmental trauma, family trauma, or betrayal trauma is not one event but the environment I grew up in was a traumatic environment. How do I know if I grew up in a traumatic environment? If I grew up anxious, had to always walk on egg shells never knowing what would happen next, experienced physical, emotional, or sexual abuse, or physical or emotional neglect, or lived in a house where there was violence, substance abuse or mental illness then I had developmental trauma.

There is a brief paper test I can take to further assess this in my life. The ACE test

(The Adverse Childhood Experiences test). You can find this online at The ACE Test.

Event trauma often leads to an acute stress reaction which can develop into a chronic Post – Traumatic Stress Disorder (PTSD) which I prefer to call Post-Traumatic Stress Response (PTSR). Post-Traumatic Stress Response is a particular syndrome with particular symptoms that need to be addressed in a specific way with evidence - based treatments that have been shown to reduce symptoms and improve day to day functioning. We will cover those specific treatments and how they are helpful.

Unlike Post-Traumatic Stress Response, complex developmental trauma/chronic relational trauma, results in a number of problems that can be different for each individual. Although there are many problems that are similar there is no one specific syndrome so there are no specific evidence - based treatments for complex developmental trauma itself. There are though, many treatment options for both the various complications and long term effects of developmental trauma as well a variety of methods that can heal the deep “heart wounds” that many of us have experienced. We will also cover these methods more in detail.

Developmental trauma often leads to what I call the Big Three” of long term effects.

These three are:

A highly dysregulated nervous system

A deep abiding sense of shame

A distorted view of self, such as worthless, no good, unlovable, defective, sick,

deeply flawed etc.

In addition, developmental trauma increases our risk of:

• Developing mood disorders, anxiety disorders, substance abuse disorders, eating disorders, impulse control disorders, and personality disorders
• Being involved in situations and relationships that increase our traumatic experiences
• Developing chronic Post-Traumatic Stress Response following event trauma
• Contributes to an impaired ability to trust, a chronic sense of powerlessness, lack of ability to experience emotional closeness, increased tendency to anxiety and stress related physical problems, a loss of spontaneity, creativity, and joy, impoverished spiritual life, social isolation and often a feeling of being only “partially alive”.

We want to focus on the big three of long term adverse effects of development trauma; A dysregulated nervous system, a deep sense of shame, and a distorted negative view of oneself but the question is “How do we do this”?

The three main components of trauma recovery historically have occurred in three different phases. This three-phased approach was initially developed by the French psychiatrist Pierre Janet in the early 1900’s. His three phases were

Stabilization

Processing trauma memories

Integration

The Somatic Resiliency approach involves those phases in a slightly different way. We do not have the time luxury of doing three-phased treatment. So, we do all three simultaneously which we have renamed the three components of trauma recovery. Modifications are:

Nervous system regulation

Reduction in shame through sharing our trauma story

Developing a more balanced sense of self and practicing life-long recovery skills

Better regulation of the nervous system is the most important task in trauma recovery and is an aspect that we review constantly. Better regulation of the nervous system is the main thing that heals us as nervous system dysregulation is primarily the source of our symptoms and interpersonal difficulties.

Historically the second phase or component of treatment of developmental trauma has been referred to as “processing” trauma. The problem with this terminology is there are great differences both between patients, and between psychiatrists, psychologists and therapists as to what “processing” trauma actually is. I prefer to use the phrase “Sharing our trauma story”. Sharing our story and how we survived is important in being heard, accepted, supported, encouraged, and reducing a sense of isolation and shame.

However, telling our story is not useful if we cannot stay regulated. Sharing our trauma story without a regulated nervous system can result in worsening of symptoms and ability to function. Many of us have had therapy where the focus has been on rehashing our trauma story. This can be useful but does not lead to long term recovery. The reason is that trauma does not reside in the past but resides currently in our body and mind as effects of the past trauma. The main purpose of sharing our trauma story is to reduce the sense of isolation and aloneness and in reducing shame. The important trauma story to tell, are those events, thoughts, feelings, reactions etc. that you have never told anyone before. Telling your story must come at your own time and own pace. You are in charge of your recovery process. Do not let any therapist push you to talk about things you may not be ready to talk about.

The third aspect of recovery is to see yourself in a new way, in a more positive light, more clarity about who you are and what your true values are in life. We do this by learning how we developed these negative ideas and feeling about ourselves and how to modify these thoughts and feelings in a way that better supports our goals in life.

Goals of Recovery

There are two main goals of trauma recovery.

Improved day to day functioning

Better quality of life

We also will look at trauma recovery objectives which I also refer to as “signposts” of recovery.

Principles of Recovery:

We focus on strengths and resources more than problems and weaknesses.

We always start with the positive first, the resources, before going into more challenging topics and areas.

Slower is faster.

Less is more.

It does not have to get worse before it gets better. It must get better before it gets better.

It is more important to know what is “right “with me than to know what is “wrong” with me.

Topics we must learn:

The roadmap

The human threat response

Built in action systems

The basics of the neuro-regulation

The nature of memory

Dissociation

Misunderstandings about the recovery process

Multiple distress tolerance, mindfulness, emotional regulation and communication skills

Brief effective cognitive assignments

The ACE study

Providing feedback

Identifying and using values

Anger management understanding and strategies

The unity of body and mind – top down and bottom - up approaches

Healthy sexuality

Healthy attitudes

The problem of “the other”

Trauma Recovery Treatments

There are a number of types of psychotherapy which can be helpful for trauma recovery.

Cognitive-behavioral therapy (CBT)

Dialectical-behavioral therapy (DBT)

Cognitive-processing therapy (CPT)

Acceptance and commitment therapy (ACT)

Eye movement densensitization reprocessing (EMDR)

Somatic Experiencing (SE)

Sensorimotor Psychotherapy (SP)

Internal Family Systems therapy (IFS)

Psychodynamic therapy

Accelerated resolution therapy (ART)

Accelerated emotional dynamic psychotherapy (AEDP)

Intensive short term dynamic psychotherapy (ISTDP)

And others

These are all listed to show there are many different types of psychotherapy for trauma recovery. There are many positive ways to go about trauma recovery. The most important thing is whatever therapy type you are participating in, to have a good relationship with your therapist who seems empathic, understanding, capable of receiving feedback, is flexible, and can switch approaches if something is not working for you. If you don’t feel this about your relationship with your therapist, leave and find someone better if possible.

Medical treatments for trauma recovery

Antidepressants

propranolol

clonidine

prazosin

some times anti-psychotics and mood stabilizers

Transcranial Magnetic Stimulation (TMS)

Biofeedback

Stellate ganglion block

Benzodiazepines and “Z” drugs are not recommended. They are potentially addictive and they stop new learning. Some common ones are Xanax, Ativan, Klonopin, Valium, Ambien and Lunesta.

Books

The Body Remembers by Babette Rothschild, both part 1 and part 2

8 Keys to Safe Trauma Recovery and/ or 8 Keys to Safe Trauma Recovery Workbook by Babette Rothschild

Helpful Attitudes to Develop:

Be hopeful, optimistic, and expectant regarding recovery

Learn to be kind, gentle, and patient with yourself – and others

We all have major flaws – we must not judge ourselves

I am not to blame for what happened to me

There will be setbacks

Slower is faster

Less is more

“Savor” the positive

Identify and know your internal and external “resources”

Be curious about yourself and mental health with no self-judgment

Celebrate your small victories

Remember changes come about when we do small things over and over again

The ‘noticing brain” (the wise mind) grows as we use it more

Perfection is the enemy of the good

The opposite of trauma is joy

We can always choose to what we attend

Misunderstandings in Trauma Recovery

I am too broken to heal

You are not broken. You have been deeply wounded. Wounds heal.

I am too old to begin addressing my trauma

You can heal at any age.

I can’t heal because the trauma happened so early in my life

Trauma lives in the present in the nervous system, the shame you carry and the negative view of self, not the past.

I have to remember everything in order to heal from trauma

It is not possible, important, or helpful to remember everything.

I need to get rid of my “bad” parts

All parts are needed

If I hear internal “voices” I must be crazy

Internal voices and “chaos” is common with severe trauma.

It has to get worse before it gets better

It has to get better before it gets better

Dissociation is bad

Dissociation is protective

People who self harm are bad and self –destructive

Self harm is a fast (but unhealthy) way to regulate emotions

I am bad, worthless, evil, or defective

A child must think this way to prevent overwhelm. You are an adult now.

Trauma Recovery Skills

Orienting

Noticing (body sensations, emotions, thoughts, movements, behavior, and the environment)

Pendulating from internal to external to internal noticing

Pendulating from more calm to more anxious areas and back to calm

Grounding Skills

Patiently tracking

Staying mindfully present

Learning to celebrate

Accept self without judgment

Add music, dance, movement, exercise, play, fun

Finding meaning and purpose

Being curious without judgment

Belong to a ‘tribe”

Care for others (unless resentful or depleted)

Ongoing Assessment with my therapist and psychiatric provider

Bring in the three things CBT assignment

Discuss how I am doing with my revised mantra

Review where I am on each signpost

Signposts along the way

Recognition that the trauma occurred and that it is “not my fault”

Better regulation of emotions and the autonomic nervous system

Reduction in shame

Decreased dissociation and somatization

Increased ability to trust and to form healthy attachments and relationships

Increased mindfulness and self- awareness

Improved communication skills

Decrease in self- harm, self- destructive, and suicidal behavior

Ability to experience and tolerate a wide variety of emotions

Improved sense of self- esteem and self- efficacy

Ability to experience a sense of aliveness, creativity, and joy

Give Feedback What is working, what is not working with:

My overall treatment

My relationship and work with my therapist

My relationship and work with my psychiatric provider