Post-traumatic Growth: From Heartache to Hope

1. Post-traumatic Growth:From Heartache to Hope Lisa Ferentz, LCSW-C, DAPA www.lisaferentz.com Lisa107107@aol.com 410-486-0351

2. Historically, the mental health field has focused on the ways in which traumatic events have caused emotional, psychological, and cognitive dysfunction and symptomatology. Research has been geared towards the study of PTSD as well as other adverse consequences of traumatic experiences.

3. Although the impact of trauma is real and must be treated carefully in order to be effectively processed and transcended as clinicians it is equally valuable to recognize the human capacity for resilience, and the potential growth that eventually can emerge from our struggle to cope with traumatic experiences

4. POST-TRAUMATIC GROWTH (from Positive Psychology) implies that we are capable of growth experiences in the context of suffering and struggle as well as in the aftermath of traumatic events including: bereavement and loss, HIV, heart attacks, cancer and other medical diagnoses, sexual assault, house fires, combat, refugee and hostage experiences, family-of-origin trauma, acts of terrorism, etc.

5. “Experience is not what happens to us, it’s what we do with what happens to us”Aldous Huxley The meaning clients attach to traumatic experiences, and what they subsequently do with them goes a long way towards defining the extent to which they remain stuck in symptoms of Acute Stress and Post-traumatic Stress versus Post-traumatic Growth

6. when the meaning of the event makes it traumatic • personalizing the experience: feeling“targeted” or singled out • feeling responsible for the event: “it’s because of me”“it’s my fault” • believing you could have stopped it or prevented it • believing the world is out to get you: feeling alone • feeling the trauma has made you “weird” or different • using it as“evidence” that bad things will keep happening to you or to others

7. the impact • depression • anxiety • helplessness/hopeless • isolated/alienated • intense fear • rage • chronic pessimism • loss of hope/faith/trust • increased suspicion • self-blame and shame • vulnerability to subsequent trauma

8. when the meaning of the event minimizes the trauma • believing it wasn’t your fault • seeing the event as arbitrary/coincidental and not about you • believing there was nothing you could have done to prevent it/stop it from happening • focusing on the fact that you survived it • focusing on the help you received from others • seeing it as an opportunity to connect with others • using it as an opportunity to personally grow/make a difference in the world

9. the impact • gratitude • appreciation • optimism • increased sense of faith • sense of getting a “second chance” • empowerment • personal growth • positive change • social connectedness

10. Working with clients who have been traumatized is a balancing act. Always honor and compassionately process their pain while continuing to suggest that there is a light at the end of the tunnel.Timing is essential- it may take certain clients longer before they recognize there are potential opportunities for growth in their painful experiences.

11. Not everyone achieves Post-traumatic growth, and the timing of working through and transcending one’s pain narrative varies from person to person.Post-traumatic growth operates on a continuum and may not present as a linear trajectory. Helping clients to notice even small glimmers of growth, in the midst of struggle, reinforces the process.

12. reasons why it might be challenging for clients to reach post-traumatic growth • The familiarity or secondary gain of “learned helplessness” • Hard to trust that things could actually get better and stay better after so much pain • History of “the other shoe dropping” in the past • Survivor guilt keeps clients stuck in shame • Chronic trauma makes the belief in a higher power very hard • Holding on to rage is the only way to stay in “relationship” with an abuser • Fear that “letting go” of the trauma, minimizes its importance

13. “The way in which trauma affects a particular individual has to do with the exact nature of the discrepancy between the new trauma-related information and that person’s pre-existing mental models”(Stephen Joseph, 2013)

14. PERSONALITY TRAITS ASSOCIATED WITH POST-TRAUMATIC GROWTH*a willingness to cognitively process the trauma* optimism/ *the ability to feel positive emotions*openness to new experiences*extraversion*supportive environment and socioeconomic factors*the ability to cope with struggling*believing in one’s capacity to heal*recognizing that pain is time-limited

15. The seeds of post-traumatic growth can be planted when clients have sufficiently acknowledged and expressed normal, initial existential questions such as: • “Why did this happen to me?” • “How could this happen?” • “How could I have stopped this from happening?”

16. Those questions are inevitable yet they keep clients on a “hamster wheel” because there will NEVER be good enough answers!

17. When the timing is right, a shift can occur by introducing questions such as…What can you do with it now? What will help youmove forward? Is there anything youcan learn from it?This begins to plant the seeds of PTG

18. “In the depths of winter I finally learned that within me lay an invincible summer”(Camus, 1968)

19. The shattered vase analogy(Joseph, 2013)

20. Introducing the concept of PTG into the treatment process • Takes the glass ceiling off of recovery • Installs hope for both client and therapist • Re-frames the impact and outcomes of trauma • Shifts client from black or white thinking ( I’ll never get better) to shade of grey (I can feel pain and still heal) • Shows client they can be stronger despite feeling more vulnerable

21. The seeds of PTG What is the lens that the therapist uses to assess and treat the client and their “symptoms?”

22. Processing a Case Study:32 year old, single white female. Profoundly emotionally, sexually, and physically abused by primary caretakers throughout childhood. Began severely restricting calories at 12 years old. Hospitalized four times between the ages of 13-18 for anorexia. History of cutting and substance abuse. Struggles with self-destructive relationships, has intimacy and trust issues. Been in therapy three different times.What do you focus on when presented with this case? What additional questions would you ask?

23. Did you ask…… -How did this girl creatively cope until she turned to an eating disorder at 12 years old? -How did she not jump off a bridge by 10 years old? What kept her going? How was she so resilient? -How did she summon the courage to join with three different therapists? -What creative strategies did she use to maintain a necessary attachment to abusive caretakers? -What was she attempting to communicating through her self-destructive behaviors? -what are her STRENGTHS?

24. Always remember to include questions about the client’s STRENGTHS in your assessment. -where did you find your courage? -how did you remain so resilient? -what creative strategies did you use to survive? -how did you not give up? -how have you stayed optimistic? -what resources did you draw upon? This gives the message that they are more than their trauma

25. We need social support for well-being and growth(Lepore and Revenson, 2006) • Provides opportunities for emotional disclosure • Allows for opportunities to process events • Allows for opportunities to better understand issues involved in the event • Provides validation of worth • Allows for suggestions for coping • (this describes a non-judgmental, compassionate therapeutic relationship!)

26. the “strengths based” perspective: normalizing, universalizing and de-pathologizingA lens that promotes Post-traumatic growth P ”

27. normalizing • feelings, “symptoms,” thoughts, behavioral choices makes sense, and are inevitable, given what the client has experienced, and given where they’ve come from “If you look at the behavior….. through a traumatic background, it makes perfect sense…If you’ve been.. abused for years, your entire organism and personality has been organized around your trauma.. the way they act is understandable.. they are people trying to survive” (Bessel van der Kolk, 2004)

28. When a client does reveal a “symptom” let them know it “makes sense” given where they’ve come from and what they’ve endured. This helps make a connection between their past trauma and current struggles-moving them away from the idea that they are “defective” or inherently “bad.”

29. universalizing • although every client’s story is unique, millions of people have experienced sexual, physical abuse and other forms of traumatic stress • anyone who is experiencing trauma is hard-wired to go into a fight/flight or freeze response- typically freeze! • unresolved traumatic experience leaves behind tangible cognitive, somatic, and psychological residue • people who have been traumatized can think, feel, and behave in very similar ways

30. de-pathologizing • It’s not about being crazy, mentally ill, or damaged, it’s about trauma • moving clients from “I’m bad” (internal attribution) to “something bad was done to me” (external attribution) • letting go of all-embracing diagnoses that define who people are (“borderline,”“bulimic”) and focusing, instead on what they experienced, how they historically coped with traumatic events, and how they can move towards healing

31. advantages of a strengths based perspective • emphasizes resilience, creativity, intelligence, courage, strength, empowerment, and responsibility • eliminates power struggles re: diagnoses • removes the “glass ceiling” that diagnoses impose on progress • strengthens the therapeutic alliance • allows for genuine trust • infuses the work with hope for clients/therapists • separates you from other helping professionals

32. advantages of a strengths based perspective • allows clients to “connect the dots” and make sense out of confusing symptoms • allows clients to shift from “I’m crazy” to “I’ve been traumatized” • allows for alleviation of shame/guilt when symptoms are re-framed as coping strategies • creates opportunities to explore alternative coping strategies • teaches clients that they are more than their trauma experiences • highlights internal resources rather than impediments • invites the use of “healthy parts” within clients • plants the seeds for Post-traumatic Growth

33. The seeds of PTG Tracking how clients talk to themselves about themselves: introducing the concept of self-compassion

34. There is nothing more powerful than the messages clients give to themselves about themselves. This monologue impacts:-the extent to which they criticize themselves-whether or not they can feel empathy and compassion for their mistakes and are able to learn from them. -whether or not they go out of their comfort zone, take healthy risks, and expand life experiences. -almost all of their thoughts, feelings, and behavioral choices -the ability to be self-protective-the ability to create and sustain intimate relationships-the ability to be a nurturing and available parent-whether or not they trust their own instincts- their confidence and self-esteem

35. It’s important to recognize that many clients operate from an inner monologue that is FROZEN IN TIME and does not represent an accurate narrative about their current abilities, resources, choices, circumstances, or age. Check for accuracy and relevancy!Also, the way in which they talk to themselves is often their perpetrator’s voice superimposed over their own. Asking “whose voice is that?” can be a first step.

36. When negative messages prevail:Listen to, acknowledge, validate and honor these thoughts and feelings.Give the client permission to have them- otherwise you create a power struggle.Explore the ways in which these thoughts and feelings serve a “protective” function.Suggest the possibility that there may be another part of them (the “wisest”, compassionate part) that has the capacity to re-frame trauma, and is open to exploring the facets of Post-traumatic growth.You can also use a “remembered resource”

37. EXPERIENTIAL: Visualize someone from your past or present, alive or deceased, who truly believed in you and loved you. Imagine you are sitting together in a safe, comfortable place. Now write yourself a letter from that resource: • What would they tell you about your capacity to survive your pain and heal? • How would they re-frame your negative experiences?

38. The seeds of PTGre-framing cognitions so they are kinderWhen you hear an unkind thought, PAUSE the work and ask…

39. *Is there a softer, less judgmental way you can talk to yourself about that issue?*Is there a kinder way to say what you just said?*Can you express that thought in a way that would help motivate you to grow and move forward in life ?*Is there a way to say that so it’s less critical or judgmental?*Is there a way to say that so it doesn’t evokefeelings of embarrassment or shame?

40. *What if you experimented with a thought that focused on your strengths and the meaningful contributions you have made, rather than on what you believe to be your weaknesses or “failures?”*What would it mean if your negative self-talk was wrong??*When you say it in a kinder way, what emotions, images or body sensations surface for you?

41. When no other resources for re-framing show up in the therapy room, allow clients to introject YOU!“How would I express that idea in a kinder way?

42. The seeds of PTGNoticing the double standards (David Burns)

43. If their best friend experienced the same trauma how would your client think about it, feel about it, and talk about it with them? (This is another way to access kindness!)When a child falls down and gets hurt, what helps and what makes it worse? How does that fit with the way they respond to their own hurt inner child?

44. The seeds of PTGhighlighting disclosures of resiliency

45. 5 things resilient people say to themselves (Jan Bruce, 2015) • Mistakes are just slip ups or errors, not indicators of a deep flaw • Stressors are challenges to be grappled with and overcome, not an indicator of life being out of control • Not having enough time in the day is an invitation to choose and prioritize, not an indicator of being trapped • Hurting someone’s feelings is an opportunity to apologize and make amends, not evidence that they are a bad person • Looking in the mirror allows for an emphasis on strengths and boosts confidence, rather than highlighting limitations or increasing self-criticism

46. Assessing for resiliency and other personal attributes(Tedeschi and Calhoun, 1998) • What were you like before this happened? • What has been your typical way of responding to a problem? • What was the hardest thing you have had to face before this happened? How did you address that? • Have there been instances where you sought out new experiences? • Think of a time when you did manage to get through difficulty.

47. indicators of Post-traumatic Growth • Ability to process post-traumatic stress symptoms in ways that lead to new insights, perspectives, and growth • Increased feelings of autonomy and mastery • Increased positive relations with others • Greater self-acceptance

48. indicators of Post-traumatic Growth • Greater sense of purpose in life • Ability to translate losses into new gains • Willingness to shift one’s goals, expectations, and assumptions about life and oneself • Experiences of positive change may be domain specific rather than all encompassing

50. A NOTE OF CAUTION“..The widespread assumption that trauma will often result in disorder should not be replaced with expectations that growth is an inevitable result. Instead, continuing personal distress and growth often co-exist”(Cadell et al, 2003)Trauma is not necessary for personal growthTrauma is never a “good” thing to experienceNot everyone reaches post-traumatic growth