Surfing the Wave of Activation

1. Surfing the Wave of Activation Using Resources when Working with Cancer Trauma

2. Goals for today’s presentation • Cancer as potentially traumatic, “life threat” • Overview limbic system, stress response • Introducing Self Regulation Therapy • Implications for working with cancer pts • Accessing Resources • Case Examples- Group, Individual • Specific applications with cancer pts

3. Definition of trauma Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning…they generally involve threats to life or bodily integrity” (p. 33, Herman, 1992)

4. Cancer sometimes experienced as traumatic… • Surgery (anesthetic) • Invasive treatment (eg immobility, needles) • Diagnostic tests • Waiting, waiting, waiting • Patient identity • Fear of recurrence “System is on red alert”

5. Who is more Vulnerable? • Past experiences • Family of origin • Intensity of the experience • Current supports and conditions • Age • Gender • Socio economic status

6. The Stress Response What is Stress? - Stress is the physical, mental or emotional tension experienced in reaction to an event. What is the FIGHT-OR-FLIGHT? -When you encounter a stressful situation, a variety of physiological responses take place.

7. Brain Physiology

8. The Blessing and the Curse of Imagination • “Bear” in the woods- we need to be able to respond quickly • Our physiology does not distinguish between real and imagined • Fight/ flight activated around interpersonal stressors, “worries” • Note – “freeze” is another possible response

9. Self Regulation- Quick Snapshot • Work with the limbic system first, then with cortex (meaning) • Reduce activation in the nervous system • Discharge flight/ fight energy • Boost resources

10. SRT – Change in Practice • Less likely to allow patient to weep in silence for a long time • More active around interrupting a negative downward spiral • More likely to slow things down, use my voice and words as a “brake” • More active around asking about a patient’s resources • Change the subject more often • Access imagination, breath, body sensations more • Access future imagined state- move around the time continuum • Use imagination to discharge fight/ flight energy

11. Note about Theoretical Framework • Does not have to be SRT, can be another theory • I think experienced therapists do some of these things automatically, but it helps to have a framework to know why you are doing what you do • Often helpful to share this framework with patients- can feel “crazy” when limbic system is activated; sharing the framework can be a resource, help settle the system • SRT can be incorporated in a session easily, but as with any framework sometimes “let it go” and just listen

12. How to “speak” to the limbic system • Limbic system is non verbal • You can not talk to “it” with words • Need to use non verbal approaches eg sensation, imagination, breath • When limbic system is “on”, often cortex is “off” • “Deer in the headlights”

13. Activation • The term used in SRT to describe that jittery, hard to settle anxiety, response to stress • Activation builds in the nervous system as a result of traumatic events (e.g., developmental trauma, car accidents, falls, surgeries, invasive medical procedures, life threatening situations, natural disasters) • Cancer can sometimes be the “straw that breaks the camel’s back”

14. What is a Resource • Can be anything that induces a calming, settling in the nervous system (relaxation response) • Can be imagined or real • Can be a thought, image, sensation (tingling, warmth, breath, support of the chair)

15. Trauma and Resource Vortices • Weave between activation and resource • Only work with small amounts of each • “Dip your toe” • Eg. Track the path of one tear… Track your in breath, out breath

16. Surfing the Waves • Metaphor: “Sipping” the ocean • Working with small amounts of a resource and small amounts of activation (titration idea) • Moving back and forth between the vortices

17. Accessing Resources When trying to decide what resource to target? Ask what is the missing resource eg, if time is the missing resource, have person imagine own personal supply of time

18. Access Sensation • Where do you feel a little bit better? Even just a little bit? • What are the sensations of comfort like? • Please just take a moment to savour these sensations, and to “book mark” them, what is it like when your body is comfortable

19. Notice “breath” “Fear is excitement without the breath” • Have someone notice where they are breathing, how they are breathing, what happens when they notice they are breathing • Track one breath • Track in breath, out breath • Track temperature of the breath

20. Access Imagination • What is that sensation like in your chest • What does it look like, a picture, what is it made out of, texture etc • If you could change that picture in any way to make it feel just a tiny bit better, how would you change it • Imagine that change… even 1 %

21. Access “Meaning” • Offer a reframe, a different way of thinking • Have someone notice what happens in body when he/she thinks that new thought • Get curious about that difference • What would a day be like if they believed that new thought, even a little bit • Imagine the new day

22. Imagine the way you want something to go • Use creative visualization to imagine the “perfect surgery” experience • Imagine resources to support this • Have patient imagine it going well, supportive doctors, nurses; angel to watch over him etc • “Positive” worry – use this energy to imagine it going well

23. Finish the Story • With traumatic experiences, one sometimes gets “stuck” in the worst moment • Can ask someone to think of a time when s/he felt safe again, were in less pain, were able to move freely • “Just take in that you are alive now, in this moment” Eg use this with medical procedures

24. Move around “time” continuum • Do not have to listen to the story in a linear fashion – bounce between past, present and future/ avoid the rote reporting of events • Interrupt a negative downward spiral by changing the time frame • Imagine you have a video camera – and you can fast forward, pause, stop, view from a safe distance etc

25. Working with Small Change • Imagine the 1% difference • Track the path of one tear • Take in one molecule of the love that surrounds you “Dipping the toe” in both the resource and the activation

26. Case Study – Use in Groups • Online support group for caregivers, taking care of a loved one who is dying • As a facilitator, I “read” the cues that I have re: activation and modulate this using resources • Example: slowing down the pace, asking group members to access resources, using humour

27. [14:13:07] A: finding this very hard to talk about, big lump in my throat... (about a documentary on end of life issues) • XXXX • [14:13:31] Heather: Slowing down, slowing down... sending care • XXXX • [14:16:38] Heather: Because we are close to time, I would like to shift our focus for a moment... can each of you look around the room you are in and see one thing that makes you feel a little lighter and hopeful... when you see it let us know what it is • [14:17:13] J: Toys for grandchildren for Christmas. • [14:17:14]A: a picture of my five granddaughters up on the wall... • [14:17:20] C: pictures of my grandkids, with big cheeky grins • [14:17:57] Heather: A picture of my kids and a poster with the word "Courage" and a beautiful picture • [14:17:59] A: picture in my mind of all of us caregivers together giving big, reassuring hugs... • [14:18:47] A: I can feel the strength in all of your arms...

28. Case Study: Cathy • Cathy, age 57; husband Geoff has bony mets, stage 4 urothelial cancer • They have three adult children, son has moved home to help with dad’s care • They have been married 34 years • They have travelled a lot as a couple; travelling is a resource • Cathy is terrified that husband will die and she will not be able to cope

29. Case Example- Individual • I have been meeting Cathy individually; in our third session she speaks openly about her fears around her husband’s death • She begins to cry and says she will not be able to cope, obvious look of fear on her face (trauma vortex) • I ask her about trips she and her husband have made; how have they prepared when they travel to a new place, how do they plan for the trip (resource vortex)

30. Offer a reframe • Talk about death as preparing for taking a trip to a new place… only this time they each need to prepare a little bit differently • They have always planned their trips very carefully down to where they will go for dinner in a new country, tourist attractions to visit etc… • Work with this metaphor of preparing for a trip to help her access her resources and know how around planning for a trip • Encourage her to talk to her husband about this also – how will they prepare together

31. The conversation continues • We shift back and forth between trauma and resource – this idea of a trip really fits for her. She becomes more animated, more hopeful as she begins to view preparing for death in this way. • Also talk about self care – how did she take care of self when she had newborn babies (she had twins) – same goes for care giving for her husband now eg nap when he rests instead of continuing to work

32. Working with psychological reactions to cancer- related issues • Post- Surgery, Anesthetic • Breathlessness • Chemo • RTX • Unknown future

33. Working with post - surgery/ anesthetic response • Have someone remember when they knew they would survive surgery, felt a bit better etc • Work with “I’m alive” • Working with anesthetic response can look like dissociation, person can look and seem sleepy, not well connected to their body • Have someone notice what happens when his/her energy leaves body • Track this and notice when they feel more “in” and more “out” • Move around the time continuum and access resources • Work with boundary rupture, left and right, front and back • Slow things down

34. Working with “breathlessness” • Breath is often used as a resource • If someone can’t catch their breath, or has difficulty breathing, find another resource, place of comfort or grounding in the body • Have someone imagine he/she has their own personal supply of oxygen • Imagine body breathing you • Notice the part of you that is breathing- even a little bit

35. Working with chemo fears • Find out what fears are around chemo • Have person imagine that the chemo is very intelligent, will only target the tumor and spare organs, surrounding tissue • Reframe chemo as medicine as opposed to poison • Imagine “colour” of chemo, can it be imagined as a healing force? • Imagine the tumour as smaller, less dense, a different colour etc

36. Working with RTX • Claustrophobia – track breath, imagine all the space you need • Work with flight activation- imagine the escape route from the hospital/ from the room, have pt practice this in their imagination with you • Work with the resource of the weight of the body on the bed, or sensation in your toes etc • Imagine RTX beam is very intelligent, specific, only targeting tumour etc

37. Working with Unknown Future • “I’m alive” in this moment, sense into that, sing like a lullaby • Imagine self at some future goal event eg. daughter’s wedding, birthday party five years from now • Imagine your own personal supply of time, “Time in a Bag” – enough time to do everything you need to do and more; see yourself getting everything done with time to spare • Telescope down this moment – if it is okay let’s just imagine you have all the resources that you need for this moment, just focus on being in this moment etc

38. Want more information? Websites: SRT website (www.cftre.com) Books Waking the Tiger: Healing Trauma (Peter Levine, 1998) The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. (Babette Rothschild, 2000)

39. Questions, Comments…