Shea Alexander, LPC-S Monica Urbaniak, LMFT-S

Point at which the survivor engages with the advocate/agency ◦ Hospital

◦ Crisis Hotline

◦ Court Accompaniment Request

◦ Speaking Event/Training Session

◦ Outreach Events

◦ Other

RAINN

TAASA

Local Agencies

Local Mental health practitioners

Law Enforcement

Hospital ER

Religious/Spiritual Communities

Other clients

Internet searches

Intervention Refresher

Challenges

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

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

Establish Rapport

Isolate the Problem

Explore Options

Encourage Action

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

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

Group brainstorm

Overview – Brain/Trauma

Importance of understanding how the brain functions during and post traumatic experiences

Biochemical:

◦ Flow of adrenaline, noradrenaline (epinephrine and norepinephrine)

◦ Release of Glucocorticoids/Cortisol

◦ Oxytocin, Vasopressin and Opioids

Physical

Psychological

Relational

Cognitive

Behavior

Spiritual

Newer Intervention Models

Mindfulness

Cognitive Based Strategies

Behavior Focused Strategies

Systemic/Ecological Approach

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

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.

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.

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?”

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.

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)

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.

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

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

Establish rapport (Relational): ◦ Acceptance ◦ Normalization ◦ Understanding of cultural, personal, and

family & social values ◦ Empathic positive unconditional regard

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

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

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).

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.

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.

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.

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.

Group Brainstorm

Katie

Tammy

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

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

Which model of treatment/intervention techniques might be effective for the client in the case example?

When to ask for help

References

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

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