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TSR Training for Veterans. David A Fohrman, M.D. What is TSR Training?. Traumatic Stress Resiliency (TSR) Training is a program to teach you how to avoid getting PTSD Essential to Have Easy to learn Takes about 30 minutes. What is the Problem?.
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TSR Training for Veterans David A Fohrman, M.D.
What is TSR Training? • Traumatic Stress Resiliency (TSR) Training is a program to teach you how to avoid getting PTSD • Essential to Have • Easy to learn • Takes about 30 minutes
What is the Problem? • Veterans have a high risk for getting Post Traumatic Stress Disorder (PTSD) • Veterans also on active duty • In national guard or reserves • For example, approximately 30% of the OIF/OEF veterans have impaired due chronic PTSD symptoms • With each deployment, the number goes up • Veterans have a 90% of experiencing a non-military related traumatic event • These traumas can lead to PTSD • higher risk if already have PTSD, from combat or non-combat related experiences • had a traumatic brain injury (TBI)
What is the Problem? • PTSD symptoms (such as flashbacks, nightmares, chronically feeling jumpy, irritable, angry, anxious or depressed) cause serious problems • at work, home, in life • Lose job, marriage, friends, interests, life (suicide) • PTSD can be very difficult to treat • especially chronic PTSD (having PTSD symptoms for more then six months)
What is the Solution? • Prevent PTSD before it develops • Diagnosis of PTSD • Wait at least 30 days after traumatic/stressful situation ends • In case of a deployment, time closer to 3-6 months • If symptoms resolve prior to this window, will not get PTSD • If you already have PTSD from prior deployments/non combat related traumatic situations, TSR training can still help
TSR Training • Helps avoid road blocks that keep your body from naturally recovering from the effects of traumatic events. • Two parts • #1: What is PTSD • #2 What are the six road blocks to recovery and how can we avoid getting them
What is PTSD? • PTSD is biological problem • A disorder due to our brain’s creating abnormal trauma induced memories. • These memories cause you to experience almost all of the symptoms of the symptoms of PTSD • Intrusive recollections of trauma • Avoidance and numbing symptoms • Hypervigalence and hyperarousal symptoms
What is PTSD? • PTSD is a spiritual problem • A disorder due to the creation of abnormal trauma induced faulty beliefs • Traumatic events can cause people to lose previously held core beliefs • Core beliefs are things you believe to be true but don’t think about • Examples are when I go through a green light other drivers will obey the traffic signal and stop • When I really need help, people I trust will help me out. • As a result of trauma, people can become lose their self confidence, not trust other people, become very cynical, think everything is ‘worthless or meaningless’ and/or may lose previously held religious beliefs
What is PTSD? • PTSD is a disorder due to a failure to naturally recover from the effects of trauma • All traumatized people temporality have some symptoms of PTSD • People get PTSD when they are unable to naturally recover • They don’t recover because trauma creates six road blocks to recovery • Soldiers have not been taught how to avoid these roadblocks.
Six Roadblocks to Recovery #1 – Can’t feel safe #2 – Can’t relax #3 – Emotionally isolate self #4 – Unable to stay in optimal zone for recovery #5 – Avoid talking about trauma #6 – Unable to fix trauma created faulty beliefs
Six Steps to Recovery • Use mnemonic: GROWTH • G – Go to a Safe place • R – Relax • O – Open Up • W – Wait until you are ready • T - Tell your story • H - Heal
GROWTH: Go to a Safe Place • Feelings safe means feeling both physically and psychologically safe • Physically safe – feel will not be unexpectedly hurt or killed • Psychologically safe – feel will not be taken advantage of while experiencing strong negative emotions
GROWTH: Go to a safe place • Examples, • At home • With friends • Doing an activity you enjoy • If you are doing something you enjoy, you feel safe • Can use handout to help you figure out what is a safe place for you
Roadblock #1: Don’t feel safe • Traumatic events can make us chronically feel unsafe • Like we might unexpectedly be in a life threatening situation • may sit with back against wall in restaurants • Avoid or really dislike crowds • For those that have never experienced this feeling • Like not having enough oxygen • Very hard to do anything other then try to feel safe
Avoid Roadblock #1: Don’t feel safe • Regain sense of safety after trauma. • Practice gradual exposure technique • When something makes us feel afraid one of two things happen • We freak out, panic, feel horrified, helpless, etc. • We stay in control; with time, anxiety will go away • Each time we stay in control will feel less and less anxious anxiety time
GROWTH: Relax • May think of one goal for relaxation: • ‘de-stress’ • Two Goals: • 1. contain excessive emotion • 2. regain a sense of being in control
Roadblock #2: Can’t relax • Traumatic events can make it hard to relax • Chronically activate fight or flight response • Feel anxious nervous, increase heart rate, blood pressure, dilate pupils • Can’t relax while fighting or running away! • Trauma are events where things are “out of control” • Can chronically feel this way
Avoid Roadblock #2: Can’t relax • Relax after trauma by having relaxation techniques that work for you • Can use breathing technique, described in handout • Use any other technique that works • Literally hundreds of books in library, book stores • Can use tapping technique to make flashbacks go away • Make sure you can feel in control “again” after trauma • Figure out what you enjoy doing • Hobby, sport, work, being a parent, • Do this in “easy way” after trauma to help you feel in control again. Can use relaxation techniques to help with prolonged exposure
GROWTH: Open up • Collectively, we can emotionally deal with what we can not deal with alone • True both in military and civilian settings • Enemies that are emotionally resilient are very difficult to beat • Examples are soldiers during war of Independence • True psychologically and biologically!
Roadblock #3: Emotionally Isolate Self • Traumatic events are situations were people close to us can be hurt or killed. • When this happens there is a natural tendency to emotionally pull back • For a limited period of time • Like having a rubber band snap on ones fingers • More cautious next time • Problem: people choose to constantly isolate self • minimize emotional contacts
Avoid Roadblock #3:Emotionally Isolate self • Use handout: Suggestions for Opening Up • First talk about Easy Topics • Then talk about more difficult topics • Talk about the what, where, when, how for each topic
GROWTH: Wait until you are ready • Wait until you are ready • You need to be in your “optimal zone for recovery” before continuing • If you are below your optimal zone – your brain will not process memories • This happens when you drink alcohol, use drugs or actively avoid thinking about the trauma • If you are above your optimal zone, you will not re-process your abnormal trauma induced memorieswhich will make it harder to fix them in the future
Avoid Roadblock #4: Can’t fix abnormal trauma memories • When your ready to recover, make you’re you are in your “optimal zone for natural recovery” • Some people are ready to start recovering a day or two after the event, others wait weeks or a couple of months • Use the handout: Optimal Zone for Recovery” to make sure your brain is biologically in the right place before you talk about the trauma with someone else. • Doing this will increase the speed in which your brain will fix it’s abnormal trauma induced memories
GROWTH: Tell your story • The best way to recover from the effects of trauma is to talk about it • Name for this: Natural Debriefing • Teaches you how to naturally debrief • Something we do often do after a stressful day • We talk to a spouse/significant other or a loved one • Talking doesn’t change ‘what happened” • Still, we feel better • In case of trauma • Talking also helps brain re-process trauma created abnormal memories • Easier said then done • We don’t practice talking about trauma • Trauma usually a rare event • Something people keep to themselves
Roadblock #5: Avoid Talking about trauma • Traumatic events bring up: • very strong emotions like horror, helplessness, intense fear, anger, shame, guilt • Thoughts, beliefs about ourselves, others or the world that are very distressing • “It was my fault” • “I can’t trust anyone because of what happened’ • Natural not to want to talk about, let alone think about, these things
Avoid Roadblock #5: Avoid talking about trauma • Practice by: • First thinking of something that bothers you • if have a hard time, think of a time when you “over reacted’ to something – for example, became angry for little or no reason • think about something that irritates you; bothers you only a little • write down, in outline form, what happened • use handout: Tell your story for an example • tell this story to someone else • if feel overwhelming emotion, stop • main thing is the process • does not matter how long you speak as long as you stay emotionally in control
Session #6: Heal Healing occurs when your past traumas no longer holds you back from living your live the fullest • Healing occurs in two ways: Biologically, Spiritually • Biologically • reprocess abnormal trauma induced memories • Spiritually • Fix any trauma induced faulty beliefs
Heal Biologically • Process abnormal trauma induced memories • Stop uncontrolled reactivation of event, flashbacks, etc. • Stop excessive fight or flight activation • Stop startle reaction, irritability, hypervigalence
Heal Biologically • Fill out the PTSD symptom checklist, any symptom you have more then ‘rarely’ is a positive response • If you have any positive response, use the GROWTH technique to help make these symptoms go away. • If you still have symptoms for more then two months after using these techniques, get additional help! • PTSD can be very difficult to treat!
Heal Spiritually • Trauma causes us to lose things important to us • Both concrete/specific and beliefs • This causes us to: • disconnect with ourselves • “live in your head” and become excessively stoic • disconnect with others • Emotionally as well as physically • disconnect with our beliefs/ideals • Start questions basic/or long held secular and/or religious beliefs
Heal – reconnect to yourself • Identify if you are disconnected • Difficulty experiencing/expressing intense emotions • Experience unexplained medical problems • Heal by being able to experience emotions without getting overwhelmed • By body sensations • Thoughts • Recover from unexplained/stress induced medical problems • Especially gastrointestinal, headaches, other unexplained aches and pains • Sexual dysfunction • Need to be able to express intimacy and aggression
Heal – reconnect to others • Identify if you are disconnected • Physically isolating oneself • Emotionally isolating oneself/avoiding emotional intimacy • Honestly/behavior will tell you if this is an issue • What would an ‘fly on the wall’ say you are doing • Often held back in emotionally reconnecting because of our trauma induced beliefs
Before being traumatized (1) I am in control of my life (2) I am competent. (3)I can reach my goals (4) What I think, feel, say and do effects other people (5)I can control how I spend my time (6) I am usually pretty healthy person After being traumatized (1)My life is out of control (2)I am basically incompetent. (3) I can’t accomplish what I set out to do (4)My actions, thoughts, and feelings do not affect any one but me (5) I can not take control of how I spend my time (6) I am usually sick Heal -reconnect to your beliefs Handout - Identify if you have trauma induced beliefs
Heal re-connect to your beliefs • Use questioning of beliefs as an opportunity to growth • Other cultures view trauma as a rite of passage • Opportunity to grow • Researchers have a name of this: Post Traumatic Growth • As a result of living through a potentially life threatening event, people often report they now • ‘try to live each day to the fullest’ • ‘do things (like hobbies, going on vacations, etc.) that they had put off doing before’ • ‘feel that their life is more meaningful’ • ‘are closer to their friends and family’ Pragmatically – emphasize decision to prioritize “connecting”
Change your actions, change your life • Use OIA acronym. • Observe • Imagine • Act • Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to • examples: spouse tries to talk to you, you pretend not to hear him/her • first identify situation retrospectively, then Use OIA acronym. • Observe • Imagine • Act • Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to • examples: spouse tries to talk to you, you pretend not to hear him/her • first identify situation retrospectively, then
Imagine • Imagine – how you would act if you wanted to emotionally connect • example – spouse talks to you, you listen • Use active listening skills • We all have them, but don’t always use them • Identify at what stage of moral development client is – speak to them at that level • Practice scenarios that could happen
Act • Act as if you want to emotionally and physically connect • This may or may not be connected to your current beliefs • May be an ‘act of faith’ • Faith means different things • This is secular • Refers to acting in a way you hope (or wish) were true even though you may not belief it’s true • Act first, and your beliefs will follow
Final points • Trauma happens! • PTSD and other long term post trauma problems don’t have too • Can use GROWTH to help you and your loved ones recovery from the psychological effects of deployment. • G - Go to a safe place • R - Relax • O - Open up • W -Wait until you are ready • T - Tell your story • H - Heal