Expressive Therapies for Affect Regulation with Trauma Survivors

1. Expressive Therapies for Affect Regulation with Trauma Survivors Lisa Ferentz, LCSW-C, DAPA www.lisaferentz.com lisa107107@aol.com 410-486-0351

2. When children have emotionally available and consistent caretakers, they develop secure attachments.Healthy attachment equals affect regulation (the ability to mange one’s emotional states). They first inter-regulate and then auto-regulate as they internalize positive soothing. The lack of good attachment leads to affect dysregulation

3. children who are not allowed to successfully attach have chemical systems that don’t develop normally, and as a result, they are in a perpetual state of physiological distress.

4. When clients have affect dysregulation and can’t manage their emotional states, doing trauma retrieval work leaves them vulnerable to flooding and de-stabilization

5. Clients need to function in an “optimum window of arousal” so they can tolerate and handle anger, sadness, and other difficult emotions and thoughts.When clients are NOT in this window, they will present as either hypo-aroused (freeze, feigned death) or hyper-aroused (fight-flight).In either of these states, they are in their limbic systems and NOT in their pre-frontal cortex. As a result, they are incapable of insight, self-awareness or the ability to process and integrate new material.

6. affect dysregulation: not in the optimal window of arousal • HYPERAROUSAL • Easily triggered • Psychomotor agitation • Hyper-vigilant • Separation anxiety • Rejection sensitivity • Emotional overwhelm HYPOAROUSAL Flat affect Numb, detached Passive, submissive Victim identity Avoidant, withdrawn Disconnected from body

7. the foundation of treatment(L.Ferentz, 2006) • creating safety and a safe place • strategies to address affect dysregulation • pacing and anchoring for stabilization • containment to prevent flooding • connection/attachment to resources and significant others

8. safety • creating a context of physical and emotional safety during sessions allows trauma work to feel reparative rather than re-traumatizing • “feeling safe” as traumatic experiences are explored helps clients to differentiate between “then” and “now” • teaching clients to ask for what they need to be safe increases their sense of empowerment and control

9. safety • clients often need to be convinced of the value of incorporating a sense of safety into treatment, as feeling safe may not be normalized for them in their daily lives • clients often want to move ahead before safety is established, unconsciously re-enacting a lack of safety in the past

10. Using the metaphor of pre-maturely jumping into the deep end of the pool • without reassurance that there is water in the pool • without checking the water temperature • without wearing a lifejacket • without checking to see if there is a lifeguard on duty • without reassurance that they know/remember how to swim

11. therapists and clients should work together to assess and create both external and internal safety before trauma work begins. external safety relates to the dynamics within the therapy room, internal safety relates to the client’s “felt sense” and subjective inner processes.

12. creating external safety • room temperature • inside/outside noise • physical proximity to therapist • arrangement of furniture • changing seating • use of artificial and natural lighting • phone ringer off/on

13. creating external safety • visual distractions or triggers • objects for anchoring • agreed upon time limits • agreed upon use of comforting physical touch • use of pillows/blankets and other comforting objects • verbal/non-verbal signals to communicate “stop”

14. creating internal safety • using soothing breath work • inward focus with safe space in front of closed eyes • visualization and collage of real/imagined “safe place” (activate the 5 senses) • visualization/collage of an inner protector

15. enhancing internal safety with breath work -E,I,E,I,O -inhale 4, hold 4, exhale 6: add words -inhale (to top of head) say “I Am”, exhale (through feet) say “here” -inhale- close fist, exhale- open fist hand on forehead/hand on heart hand on belly/hand on heart- add figure 8 rock

16. Debbie’s safe place • a small, white boat with comfortable blue padded seat and a soft pink blanket • covered in a shimmering silver net • anchored in clear, aqua water • gently rocks back and forth • the sun is shining, warm. There is a cool breeze • the air smells and tastes salty • there are sounds of water lapping the boat and birds overhead

17. arousal modulation • trauma survivors react more intensely to stimuli • once arousal is activated, the traumatized brain does not have the ability to calm itself • the deficit regarding self-soothing is also related to a lack of attachment in childhood

18. Hand in Hand Meditation re-connecting with sensation in the body is one way to pause, re-ground, and modulate emotion

19. EFT: emotional freedom techniquesincorporating tapping

20. EFT: Emotional Freedom TechniqueGary Craig • based on Chinese meridian/ acupressure points on the body • identify a negative feeling/something that is bothering you • notice where you feel it on your body • rate the intensity from 1-10 • name the feeling • the feeling is “nervous electrical energy” that is stuck on the body • tapping “cleans out” the blocked energy

21. EFT protocol • “set up” by starting with “karate chop” point and saying, Right now I feel______, and I deeply and completely accept myself” • continue to focus on the feeling and pair it with remaining pressure points on the body • rate the level of intensity • continue to repeat the sets until the intensity drops down to a 1

22. “anchoring”(Babette Rothschild, 2000) • a concrete, observable resource • a person, animal, place, object, activity that gives the client a feeling of well-being and relief • something that can be recalled with all of the senses • used as a “braking tool” when therapy becomes too emotionally or physically arousing for the client • allows the client to address charged material by preventing the escalation of hyper-arousal

23. examples of anchors • a small, smooth stone • a picture of a beloved family member • a brightly colored seashell • a favorite sweater or blanket • a stuffed animal/ a doll • silky colored scarves • pressing fingers in the “OK’ sign/yoga pose • a rosary • a wedding ring or other jewelry • a travel postcard • hand on stomach while breathing- VAH, YAH, RAH • aromatherapy- candles, lotion, teabags, perfume, etc

24. When we learn to drive a car, knowing how to step on the brake is as important as knowing how to step on the gas pedal. The same is true when we work with trauma. Teaching clients how to “step on the brake” and slow the process down, so they don’t become overwhelmed or flooded, is as important as showing them how to move forward towards healing. the soda bottle metaphor(Babette Rothschild, 2004)

25. As the client begins to access trauma material, attention is paid to their level of hyper-arousal and the activation of the sympathetic system. Rather than allowing for an escalation of arousal, we temporarily “put on the brakes” by re-introducing the anchor, tapping, doing brain gym, breathing, moving the body, heightening external safety and/or returning to the internal safe place. This brings the client back to a safer, less aroused state. Toggling back and forth between arousal and safety allows the client to proceed without becoming overwhelmed.

26. pacing with “scaling” • create a subjective template from 0-10 • 0= feeling totally neutral, not disturbed by emotion or memory at all • 10= completely overwhelmed by the emotion or memory • ask client to identify the thoughts, feelings, body sensations that accompany 0-10 • agree to “put on the brakes” when a client reaches a “5” (or whatever number begins to feel unmanageable for them)

27. “containment strategies” • reassures clients and therapists that “emotional and cognitive flooding” will not occur • helps clients feel a greater sense of control over their trauma material • strengthens a sense of boundaries • introduces notion of “working through” without being re-traumatized • increases clients’ abilities to return to the “outside world” after session and function appropriately

28. containment • turning affect/trauma material into colors and shapes • putting the color/shape into another internal container • checking for an inner sense of safety • adding additional layers of containment, if necessary

29. Sara’s containment for RAGE • large, bright orange sun with jagged red edges • absorbed into a dark wooden asbestos box with a lid and carvings on it • black braided rope tied around the box • cover the box with a scratchy, grey woolen blanket with red stripes • cover the whole thing in shimmery, silver angel wings

30. Mark’s containment emotion: despair shape and color: black, lump of coal, the size of a large fist container: bury it in a swimming pool filled with white sand additional container: heavy, black tarp covering the whole sand pit additional container: braided ropes to hold down the tarp now it feels adequately contained

31. containment • making a collage or drawing internal “containers” to store affect and trauma material • writing down untenable emotion or trauma memory and storing the paper in an actual container ( a purse, a box, an envelope, a tupperware container, a drawer with a lock on it, etc.)

32. Somatic resourcing: using the body for containing(Pat Ogden) • taking a breath • expanding the chest • re-aligning the spine • putting both feet on the floor • standing up • re-distributing weight on the floor • pressing crossed arms against inside of thighs • warrior poses • one hand under opposite armpit/other hand on opposite forearm • thumb hold

33. Ericksonian flashback halting technique(Milton Erickson) client assumes comfortable upright position, both feet planted on the floor identifies, out loud, five things they see in the room, five things they hear, and five things they feel repeat pattern, identifying four of each, then three, two, and one this helps shift awareness from senses associated with flashback to present-focused senses

34. additional work with flashbacks(Lisa Ferentz, LCSW-C, DAPA) As I experience this thought/feeling/ body sensation/image I realize I feel ______ years old. This tells me that I am having a cognitive, emotional, somatic or visual flashback I am being given information back about how I used to think/feel in the past. In the present, I can use this information to grow and heal. In the present I am strong, safe, powerful

35. attachment and external support • continue to work on non-verbal attunement with client to strengthen attachment/ trust • assess for connection to external resources for support: spiritual, 12 step meetings or other support groups, extended safe family members, colleagues and friends, 24 hour hotlines, appropriate Internet support, remembered resources

36. Working with clients who have been traumatized is a balancing act. Always honor and empathically 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 “gifts” and opportunities for growth in their painful experiences.

37. Self-Report Questionnaires for Post-traumatic Growth The Posttraumatic Growth Inventory (PTGI)Tedeschi, R.G. and Calhoun, L.G. (1996) Journal of Traumatic Stress, 9, 455-471The Posttraumatic Growth Inventory for Children-Revised (PTGI-C-R) Kilmer, R. P., Gil-Rivas, V., Tedeschi, R.G.,Calhoun, L.G. et al (2009) Journal of Traumatic Stress, 22, 248-253The Psychological Well-Being-Posttraumatic Changes Questionnaire (PWB-PTCQ)Joseph, S. Maltby, J. Wood, A.M. et al (2011) Psychological Trauma: Theory, Research, Practice, and Policy, 15, 1-9The Stress-Related Growth Scale (SRGS)Park, C.L., Cohen, L.H., Murch, R.L. (1996) Journal of Personality, 64, 71-105The Personal Growth Initiative Scale-II (PGIS-II) Robitschek, C. Ashton, M.W., Spering, C.C. et al (2012) Journal of Counseling Psychology, 59, 274-287 The Thriving Scale (TS) Abraido-Lanza, A.F., Guier, C., Colon, M.R. ( 1998) Journal of Social Issues, 54, 405-428 The Silver Lining Questionnaire (SLQ-38) Sodergren, S.C., Hyland, M.E. ( 2000) Psychology and Health, 15, 85-97

38. Using a remembered resource: 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. What advice would they give you about self-care? What would they tell you about your capacity to survive your pain and heal? How would they re-frame your negative experiences?

39. Encouraging clients to creatively document their growth through self-made videos

40. Encourage clients to use inspirational messages as screen savers on their cellphones and laptops. This offers ongoing reminders of hope and resiliency. It helps clients to be their own best cheerleaders!