Nana korobi ya oki

1. Nana korobi ya oki

2. What to do when pain never endsLillieth Grand, M.S. MT-BC WRAMTA Conference 2011

3. Framework: client as subject matter expert, therapist as supportThe therapist supports, the client guides. In the client - therapist dyad, the therapist mirrors and absorbs the client's pain

4. Overview 1 • Resiliency • Case examples • Positive outcomes versus acknowledging what cannot be changed

5. Overview 2 • Structure a treatment plan and discharge. • Roundtable • Never tear down a wall if you don't know why it was built" ,Transforming the therapeutic relationship" • When bad things happen, good things follow" explore "Capacity to be with " .

6. Resiliency

7. Resiliency, a biochemical story • Charles A. Morgan et al., Relationship Among Plasma Cortisol, Catecholamines, Neuropeptide Y, and Human Performance During Exposure to Uncontrollable Stress, Psychosomatic Medicine 63:412-422 (2001)  • Cortisol release mitigated by DHEA • CRH activation mitigated by neuropeptide Y

8. High cortisol – high dissociation

9. Resiliency,  continued • Kumar, A.M. et al, Music therapy increases serum melatonin levels in patients with Alzheimer's disease, AlternTher Health Med. 1999 Nov; 5(6):49-57 • Melatonin concentration in serum increased significantly after music therapy and wasfoundto increase further at 6 weeks follow-up

10. Resiliency,  continued 2 • Salimpoor, V.N., Anatomically distinct dopamine release during anticipation and experience of peak emotion to music, Nature Neuroscience Jan. 2011 • Intense pleasurein response to music canleadto dopamine release in the striatal system. Anticipation of an abstract reward can result in dopamine release.

11. Significant [11C]raclopride binding potential (BP) decreases during pleasurable compared with neutral music listening indicating increased dopamine release during pleasurable music

12. Number of chills reported positively correlated with percent binding potential change in the caudate consistent with the idea that a greater number of chills would result in greater anticipation and result in more activity in the areas associated with anticipation.

13. Resiliency,  continued 3 • Bonanno, George A.,The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss, Basic Books, 2009 • After six months, less than 10%of people affected by a catastrophic event continued to experience trauma symptoms

14. Resiliency,  continued 4 Wellbeing: Tom Rath, Jim Harter, Gallup Institute: positive defaults • Career, Social, Financial, Physical, Community • http://www.wbfinder.com/home.aspx

15. Case examples • Vicarious traumatization: Critical Incident Stress Management • Legacy Song: Transitional Object

16. Positive outcomes versus acknowledging what cannot be changed - 1, Discuss • David J. Berghus, Arthur E. Jongsma, Family Therapy Progress Notes Planner: Client Presentation • Accidental Sudden Death - Family members have begun to process their grief • Loss of Pregnancy - As treatment has progressed, the parents have moved through the stages of grief

17. Positive outcomes versus acknowledging what cannot be changed - 2, Discuss • Death Due to Long, Terminal Illness - As treatment has progressed, the family has begun to grief the loss of the child and found a sense of meaning in the illness and death • Death Due to An Acute Illness - As treatment has progressed, the family has begun to cope with the loss of the child • Trauma Due to the Death of a Child - As treatment has progressed, the family members appear to be less overwhelmed by the guilt and trauma related to the accidental death of the child

18. Positive outcomes versus acknowledging what cannot be changed - 3, Discuss • Changing Family Dynamics - The family has begun to function again in a more stable manner after the loss of the child • Overprotectiveness of Survivors - As treatment has progressed, the parents have demonstrated  a healthy level of protection and concern for the surviving children

19. Positive outcomes versus acknowledging what cannot be changed - 4, Discuss • Interventions: • Allow Venting of Grief  - The family was supported and encouraged as they shared feelings of grief and pain associated with their loss • Promote Unity - Family members were assisted in promoting a sense of unity among each other

20. Positive outcomes versus acknowledging what cannot be changed - 5, Discuss • Share images / share songs - an emphasis was placed on the sharing of memories of the deceased to keep that person alive in spirit • Discuss circumstances of death - Family members were supported when describing the details of the child's death – Legacy Song

21. Positive outcomes versus acknowledging what cannot be changed - 6, Discuss • Emphasize deceased living within - Family members were supported to recognize the characteristics of the deceased within each other • Object of transition - find and sustain presence • Prepare: find your resiliency song and apply it to recurring stressors

22. Positive outcomes versus acknowledging what cannot be changed - 7, Discuss • Use pleasurable (meaningful) songs as behavior change cues • Action "Pull Yourself Up" Song • Reflection "Good bye" Songs • Expression "Love" Songs

23. Viewpoints - Self Psychology • Reflective Practice • Reflective Supervision

24. Viewpoints - Behavioral -1 • R Rosser, S Dewar, Department of Psychiatry, University College and Middlesex School of Medicine, Journal of the Royal Society of Medicine Volume 84 January 1991  • Work with montage including songs , develop personal diaries and artistic material representing the experience and subsequent reactions.

25. Viewpoints - Behavioral -2 • Rose Zimering, Ph.D., James Munroe, Ed.D., and Suzy Bird Gulliver, Ph.D.: Secondary Traumatization in Mental Health Care Providers April 2003, Vol. XX, Issue 4 • Experiencing, avoidance and hyperarousal, Compassion Fatigueand vicarious traumatization  • Attend sufficient training

26. Viewpoints - Behavioral -3 • Therapist maintain wellness and promote effective coping strategies. • Therapists monitor for signs of distress, impairment that may harm the client or make services ineffective. • Teach coping strategies to client • Teach client to maintain spiritual contact with deceased

27. Viewpoints - Behavioral -4 • Conduct assessment based on Holmes - Rahe - Life - Stress Inventory • Conduct assessment based on Child Trauma Academy trauma interview • Teach Lessons based on trauma assessment: • www.childtraumaacademy.com

28. Structure a treatment plan and discharge • Create a life montage - before and after traumatic event • Therapeutic journal and therapeutic discussion • Potential re-enactment • Work towards Family Therapy Progress Notes Planner benchmarks, set becnhmarks in partnership with the consumer • Receiving and giving gifts: conduct a risk benefit analysis

29. Roundtable • "never tear down a wall if you don't know why it was built", • transforming the therapeutic relationship • "when bad things happen, good things follow" explore "Capacity to be with "

30. "never tear down a wall if you don't know why it was built" • Circle Of Security: " The worst danger isn’t that children experience fear. The worst danger comes when fear is not recognized and accepted by a safe and secure caregiver. A child’s sense of fear, when it is unattended to by a caregiver, moves in the direction of terror. The child’s sense of helplessness, when unshared and unregulated by the caregiver, moves in the direction of despair. Terror (unregulated fear) and despair (unregulated helplessness) become overwhelming for children primarily because they doesn’t feel like they can be shared with and organized by someone who is bigger, stronger, wiser, and kind."

31. "never tear down a wall if you don't know why it was built" - 2 • COS: "Hence, the goal is to find a way to give caregivers a sense of clear direction and sound encouragement in offering themselves as a resource for the management of fear and powerlessness."

32. roundtable •                     Q + A