aacc 2019 cutting edge workshopinstitute4compassionatecare.com/wp-content/uploads/... ·...

10/17/19

1

Cutting Edge Treatment for Crisis and Trauma:

Kevin Ellers, D.Min.The Salvation Army

Territorial Disaster Services Coordinator

Jennifer Cisney Ellers, M.A.Institute for Compassionate Care

Executive Director

An overview of new advances and effective models

Defining Trauma

SAMHSADefinitionIndividualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesexperiencedbyanindividualasphysicallyoremotionallyharmfulorlife-threateningwithlastingadverseeffectsontheindividualsfunctioningandmental,physical,social,emotional,orspiritualwell-being.(integration.samhsa.gov)

Types of Trauma

1.  WarandCombat

2.  ViolenceandAbuse

3.  DisasterandTerrorism

Trauma Impact

• Mostpeoplerecoverfromasingletraumaticeventwithouttreatment

• Normalpeoplewillhavesymptomsofposttraumaticstressoracutestressfollowingatraumaticevent

• Symptomsarearesultofsystemicchangesduringflightorflightresponse(AcuteStressResponse)

• Mostsymptomssubsidewithin48-72hours

Trauma ImpactAcuteStressDisorder• 3-30daysfollowingevent• flashbacks,nightmares,dissociation,withdrawal,agitation

Post-TraumaticStressDisorder•  Symptomslastmorethan30

days•  Symptomsdonotabate,

increase,impairfunctionorleadtoself-medication

Trauma Impact

ComplexTrauma/ComplexPTSD• Canbecalled• -ComplexTrauma• -ComplexPTSDorC-PTSD

• NotinDSMsonotanofficialdiagnosisatthistime• ComplextraumaislistedintheICD(InternationalClassificationofDiseases)

10/17/19

2

Trauma Impact

• ComplexTraumaorC-PTSDismorelikelytooccurwhentraumaisongoingorrepetitive

• Childhoodsexualabuse• DomesticViolence• War/Combat

History of PTSD

• RecognizedasadiagnosisintheAPA’sDSMin1980whenaddedtotheDSMIII• Atthattime,itwasconsideredanAnxietyDisorderandtreatedaccordingly• Ourunderstandinghasdevelopedandchangednowunder“TraumaandStressor-RelatedDisorders”• Manyadvancesinbothunderstandingandtreatment

Trauma Informed Care

• MostorganizationsandinstitutionsnowrecommendTraumaInformedCare

• WhatisTraumaInformedCare?

Trauma Informed Care

SAMHSAdefinesTraumaInformedCareas:Aprogram,organizationorsystemthatrealizesthewidespreadimpactoftraumaandunderstandspotentialpathsforrecovery,recognizesthesignsandsymptomsoftraumainclients,families,staffandothersinvolvedwiththesystem;andrespondsbyfullyintegratingknowledgeabouttraumaintopolicies,proceduresandpractices,andseekstoactivelyresistretraumatization.

Psychological First Aid and Trauma Therapy

• Withinfirst48-72hoursfollowingacrisis,lossortraumaticevent–recommendstabalizationthroughpsychologicalfirstaid• PFAorSPFAcanbeadministeredbytrainedindividualstoincludementalhealthprofessionals,clergy/chaplains,disasterworkersoranyonetrainedinPFA• SomenewtechniquesmayalsohavePFAapplications

Recommended Treatments for PTSD/Complex Trauma

• TraditionalCognitiveTherapiesarestillsupportedbyresearchassomeofthemosteffectivetreatments• CognitiveTherapiesaretheonlyoneslistedas“StronglyRecommended”byAPAundertheir“ClinicalPracticeGuidelineforTreatmentofPTSD”• AlsotoprecommendedtherapiesinVA/DODClinicalPracticeGuidelinesforManagementofPTSDandAcuteStressDisorder

10/17/19

3

Cognitive Therapies for Trauma/PTSD

Fourtreatments-allarevariationsofCBTarelistedasStronglyRecommended1.   CognitiveBehavioralTherapy–traditionaltalk

therapytargetingtheinteractionbetweenthoughts,feelingsandbehaviors

2.   CognitiveProcessingTherapy(CPT)–talktherapy–formofCBT–thathelpsclientsmodifyandchallengeunhelpfulbeliefsaboutthetrauma

Cognitive Therapies for Trauma/PTSD

3.   CognitiveTherapy–talktherapyfocusedonmodifyingthepessimisticevaluationsandmemoriesofthetrauma,withthegoalofinterruptingthedisturbingbehavioralorthoughtpatternsthathavebeeninterferingwiththeperson’sdailylife.

4.   ProlongedExposureTherapy–typeofCBTthatteachesindividualstograduallyapproachtrauma-relatedmemories,feelingsorsituations.

Conditionally Recommended by APA

1.   BriefEclecticPsychotherapy–combineselementsofCBTandapsychdynamicapproach

2.   EMDR–EyeMovementDesensitizationandReprocessing–structuredtherapythatencouragesclienttofocusonthetraumawhilesimultaneouslyexperiencingbilateralstimulation

3.   NarrativeExposureTherapy(NET)–helpsclientsestablishacoherentlifenarrative(story)inwhichtocontextualizetraumaticexperiences

New Trauma Models with Promise

• Briefoverviewofsomeofthemostexcitingmodelsthatwethinkhavepromiseandinitialpositiveresearch• Experimental–somehavehadnoresearch–othershavehadsomebutnotenoughtobeendorsedbymajorcounselingagencies• Cantakedecadesofusetogetenoughconsistentdatasoweneedpeoplestudyingandpracticingnewinterventions

Trauma/Crisis Models

• EyeMovementTherapies–EMDR/CIDP/ATIP

• PsychosensoryTherapies–Havening• Body-OrientedApproach–SomaticExperiencing

• AnimalAssistedTherapies–PTSDServiceDogs/EquineTherapy

Other Advances/Models

• OtherAdvances/Modelsnotcoveredinthissession1. Neurofeedback–formofbiofeedback–measuresbrainwavesorotherelectricalactivityofthenervoussystem

2. Epigenetics–“ItDidn’tStartWithYou:HowInheritedFamilyTraumaShapesWhoWeAreandHowToEndtheCycle”–MarkWolynn–SomenewresearchsuggeststhattraumacanalterDNA–andbepasseddownthroughgenes

10/17/19

4

Trauma Treatments

• Modelspecificfortraumawithmostsolidresearchforeffectiveness

• EMDR–EyeMovementDesensitizationandReprocessing

Trauma Treatments

• ResearchonEMDRshowsitiseffectiveintreatmentofPTSD

• Definitelyeffectivecomparedtonotreatment

• WhencomparedtoothertraumainformedtreatmentsuchastraumafocusedCBT–ProlongedExposure,etc.-studiesvarybutseemstobeequallyeffective

• SomestudiesshowitisbettertoleratedandhavebetterSUDSratingsfromclientsafterfewersessions

EMDR Certification

•  mustbelicensedorcertifiedintheirmentalhealthprofessionalfieldwithminimumoftwoyearsexperience•  musthavecompletedanEMDRIAapprovedtrainingprograminEMDRtherapy• MusthaveconductedaminimumoffiftyclinicalsessionsinwhichEMDRwasutilized• musthavereceivedtwentyhoursofconsultationinEMDRbyanApprovedConsultant•  12hoursCEevery2years

Eye Movement for PFA

• Thereareanumberofothermodelsthatutilizeeyemovement• NewmodeldevelopedbyanEMDRpractitionertoutilizeeyemovementinpsychologicalfirstaid• Canbeadministeredbytrainedfirstresponders,chaplains,disasterworkersorothertrainedcrisisresponder• ItisnotEMDR

CID/ATIP

• CriticalIncidentDesensitization

• AcuteTraumaticIncidentProcessing

• Botharepsychologicalfirstaidinterventionsthatcanbeadministeredbytrainedresponderstohelpgroundandstabilizesurvivorsintheimmediateaftermathofatraumaticevent–minutestohoursafter

CIDP Background

Developed by Roy Kiessling, LISW

Red Cross disaster volunteer Trauma treatment trainer (EMDR)

• Background • Overseas • Hurricane Katrina • Army Chaplains

• 2005- Developed and began teaching crisis interventions • Clinicians

• Community trauma - natural disaster, Hawaii’s false attack, school shooting, • Para-professionals • Hospice

!X

10/17/19

5

A-TIP Overview

• ATIP/CIDslidefromRoy#19in4hour

A-TIP Acute Traumatic Incident Processing

CID Ground

Stabilize

Refer

Crisis

!X

• ResearchoneyemovementwithacutestressslidefromRo#18in4hour

Research on the use of Eye Movements with Acute Stress

2014: Leer, A., Engelhard, I. M., & van den Hout, M. A. (2014). Journal of behavior therapy and experimental psychiatry, 45 (3),396-401.

• This study provides corroborating evidence that EM during recall causes reductions in memory vividness and emotionality

2011: Schubert, S.J., Lee, C.W. & Drummond, P.D. Journal of Anxiety Disorders, 25, 1-11.

• Use of eye movements led to greater reduction in distress • Heart rate decreased significantly when eye movements

began; • Skin conductance decreased during eye movement sets; • Heart rate variability and respiration rate increased

significantly as eye movements continued:

1997 – Andrade, J., Kavanagh, D., & Baddeley, A.: Eye movements reduce image vividness of emotionality

!X

Four Requirements for Traumatic Encoding

1.  Event2.  Meaning3.  Vulnerable

landscapeofthebrain

4.  Perceivedinescabability

Havening Definition

“HaveningTechniques,otherwiseknownasDeltaWaveTechniques,isapsychosensorytreatmentthatusessimpletouchtopermanentlyeliminateunwantedfeelings,bothsomaticandemotional,fromdistressingmemoriesandevents.Inaddition,thesetechniquesareusefulforpromotingprofessionalandpersonalgrowth.Themethodisderivedfromandconsistentwithcurrentneuroscienceliterature.HaveningTechniquesifeasytolearn,canbeself-applied,andisrapid,gentleandessentiallywithoutsideeffects.”

10/17/19

6

Overview

• TechniquederivedfromtraditionalChinesemedicinethatemploystouchingacupoints• InitialworkfocusedonEventHavening• De-linksemotional/somaticconentfromtheretrievedmemory• Removesthedistressingcomponents• Createssensesafetytodepotentiatetraumaticmemory

Havening Mechanisms

EventHavening:AltersresponsetorecalledtraumaticallyencodedeventTranspirationalHavening:diffusechronicemotionalstatesIffirmationalHavening:UsedtomoveindividualsalongapathtoacceptancethatchangeispossibleAffirmationalHaveningandHopefulHavening:IncreasespsychologicalwellbeingandresilienceOutcomeHavening:UsedtoaltertheoutcomeofarecalledeventRoleHavening:Clientsubjectivelyexperiencescommunicatingdirectlyeitherwith(1)anaspectofthemselves,or(2)anotherpersonnotphysicallypresentinsessionwhohassomeroleinaddressingclient’sissue

Certification

• Twodayclassroomtraining>$1000

• Certification–6monthprocess>$1000

• Onlineethicscourse

• Onlinesciencecourse

• Exam

• 30casestudies

Somatic Experiencing

• Body-orientedapproachtohealingtraumaandotherstressdisorders• DevelopedbyDr.PeterA.Levine• Basedinbiologyandneuroscienceandstudyofanimalsreactionsandresponsestoflightorflight• Offersaframeworktoassesswhereapersonis“stuck”inthefight,flightorfreezeresponsesandprovidesclinicaltoolstoresolvethesefixatedphysiologicalstates

Somatic Experiencing Somatic Experiencing

• Researchonsomaticexperiencing–somepeerreviewedresearch–positiveoutcomes–indicatefurtherresearchisneeded• Traininginitiallyopentoonlylicensedmentalhealthprofessionals• SETrainingnowopentomentalhealthprofessionals,medicalprofessionals,bodyworkprofessionals(massagetherapists)andfirstresponders,chaplains,crisiscenterstaff,mediators,clergy,etc.

10/17/19

7

AnimalAssistedTherapies&Support

Animal-Assisted Therapies

• PsychiatricservicedogsforPTSD

• Crisisresponse/comfortdogsusedin

crisis/disastersettings

• Equinetherapy/EGALAtherapy

Animal Assisted Therapies

• Animal-AssistedInterventions(AAI)• Lotsofsciencebehindtherelationshipbetweenhumansandanimalsandthehealingpotentialofthoserelationshipsphysically,psychologicallyandspiritually

• Inrecentyears,AAIhavebeenappliedtotraumaandPTSD

Animal Assisted Therapies

• ServiceDogsforPTSD• IncreasingnumberoforganizationstrainingservicedogsforPTSD

• Costcanbehigh–over$20,000justforinitialcost• Manyorganizationsraisefundsanddonatethedogsatnocosttotheclient,butmostareformilitaryveteransandtherearelongwaitinglists

Service Dogs for PTSD Animal Assisted Therapies & Support

Psychiatricservicesprovidedbytraineddogs:• Highlydevelopedsenseofsmell•  Senseshiftsinbody:heartrate,pulse,chemicalsinbody,actions• Grounding• Distraction• Comfort• Alertforanxietyandpanicattack• Promptownertotakemedication• Alertforseizure

10/17/19

8

Psychiatric Service Dog

Manypeopleassumethatpsychiatricservicedogsareanothernamefor"ESA:emotionalsupportanimal,"whichisnotonlyfalsebutalsoacompletelydifferentthing.Emotionalsupportdogsarenottaughtanyofthetaskslistedaboveandinmostcases,notanytasksatall.Granted,theymaynaturallylearntoalertbypickinguponthehandler'sanxiousbehaviors,buttheydonotrequireanytrainingandaredeniedpublicaccessrights.ESAsarepurelyforemotionalsupport,justhowitsounds,andexistingforthehandler'scomfortistheironlyjob.

How Animals Help

"OneofBucky'stasksistoalertto,andinterrupt,skinpicking.It'sanervousticandIdon'talwaysrealizeI'mdoingit.Itdoesn'tseemlikeabigdealtomostpeople,butithasleftmewithalotofnastyscars.HavingBuckyinterruptthatbehaviorcouldsavemefromgettinganinfectionandendingupwithmorescars.“"He(Anders,servicedog)keepsmefocusedonmytaskathandsoIdon'toverwhelmmyselfneedlesslyanddissociate.Herespondstoincreasingheartrate,changeinpheromoneswithoncominganxietyandphysicalmovements.Withouthishelp,mybipolarandanxietywouldmakeitimpossibleformetowork.“https://www.theodysseyonline.com/psd-tasks

Equine Assisted Growth and Learning

•  Why Horses? •  The EAGALA Model •  Training & Certification •  Cost

What’s going on here?

Why Horses?

• Aspreyanimalstheymaintainastateofconstantawarenessastheirsurvivaldependsoninstinctivelyscanningallaspectsoftheirenvironment.• Areastuteteachersofself-awareness• Keenlyalert,observant,intuitiveandemotional• Authenticandcongruent• Socialbeingsthatlivetogetherinherds

Why Horses?

• Similartoourfamilydynamicswithdefinedhierarchies,roles,responsibilities,andrelationships• illuminateourpatternsofcontact,• Giveusdirectandimmediatefeedbackonourintentions,behaviors,andincongruities.• Createopportunitiesfordiscovery,internalshifts,transitionsandchoicesforrelational,emotionalandspiritualgrowth

10/17/19

9

4 H Equine Healing Model

Holy

Horse

Healing

Human

Why Horses?

•  Similar to our family dynamics with defined hierarchies, roles, responsibilities, and relationships •  Engaging & relational

•  Size: big, powerful, present

•  Prey animal•  Sensitive• Hyper-vigilant• Herd behavior•  Flight instinct

Why Horses?•  Emotionally Safe

•  Relationship: present, embodied connection

•  Immediate, candid, nonjudgmental feedback

• Demand congruence

•  Speak language of heart

Why Horses?• Become living symbols of

other relationships

•  Puts the abstract into the physical, external space which can be touched and changed

•  The horses create opportunities for discovery, internal shifts, transitions and choices for relational, emotional and spiritual growth and help “re-write” the clients’ stories

Trauma Workers Need Horse Sense

Whatahorsecanteachus:

•  Fullypresentinthemoment• Acutelyawareoftheirenvironment• Highlyintuitive•  Speakalanguageoftheheartvshead• Arepartofaherd• Don’tjudge,careaboutpastorappearance• Provideimmediatefeedback• Congruent

10/17/19

10

RESET RANCH

Restorative

Equine and Animal Assisted

Spiritually Facilitated

Endogenous & Exogenous

Transformative

The Eagala Model

EAGALA Training & Certification

MINIMUMSTANDARDSFORAMENTALHEALTHPROFESSIONAL• Muststaywithinyourscopeofpracticeandfollowregion,state,orcountrylawsandregulationsregardingmentalhealthpractice• Mustbeoneofthefollowing*

•  Underagoverningboard/body•  Heldaccountableasamemberofanassociation•  Underprofessionalsupervisionbyasupervisorthatisheldaccountablebyagoverningboard/association

*Tobequalified,aboard/associationmusthavetheabilitytorevokeregistration,certification,accreditationorlicensureforethicalorscopeofpracticeviolationsrelatingtomentalhealthpractice

EAGALA Training & Certification

MINIMUMSTANDARDSFORANEQUINESPECIALISTMusthave6,000hours(equalsapprox3yearsfull-timework)hands-onexperiencewithhorses• Musthavecompletedaminimumof100hoursofcontinuingeducationintheequineprofession.40ofthosehoursmusthavebeencompletedinthelast2years•  Educationneedtoincludetopicssuchas:•  Groundworkexperience•  Horsepsychologyknowledge•  Readinghorsebodylanguage/nonverbalcommunication

EAGALA Training & Certification

EagalaCertificationinvolvessuccessfullycompletingfoursteps:1.  Pre-trainingonlinewebinar2.  Professionaldevelopmentportfolio3.  FundamentalsoftheEagalaModelTraining4.  Post-trainingonlineassessment

Treating Trauma: Thinking outside of Talk Therapy

“Trauma is actually NOT the story of what happened a long time ago; trauma is residue that’s living inside of you now; trauma lives inside of you in horrible sensations, panic reactions, uptightness,

explosions, and impulses.“Van Der Kolk

“To talk about your trauma sometimes separates people because you are into your own misery and your overwhelming feeling of

terror and rage.”Van Der Kolk

10/17/19

11

The Eagala Model

•  Global standard for incorporating horses into mental health treatment for people

•  Over 2,500 certified members in over 40 countries

•  Only association offering a fully-developed, professionally endorsed treatment model of mental health practitioners practicing EAP

The Eagala Model

Four Tenants:

•  Team Approach

•  Focused on the Ground

•  Solution-Oriented

•  Code of Ethics

Find an Eagala Program in Your Area

500 Eagala Programs worldwide

Developing Your Program

Eagala®

Training, Certification, Locate a Program

www.eagala.org (801) 754-0400

Thank You!Questions?

Conclusions

• Ifyoudoanyworkwithtrauma–getasmuchtrainingasyoucan• Ifyouworkprimarilywithtraumaasspecialtyarea-considerspecializedtraininginatreatmentmodalitythatappealstoyou• Considerthetimeandcostinvolvedandhowoftenyouwouldbeabletousethetreatment• Findcertifiedpractitioners(preferablyChristiancounselors)inyourcommunity

10/17/19

12

Collaborative Relationships for TX

• RecommendstartingwithTrauma-informedcognitivetherapies• Considersupplementing(forthosewhoneed)withothertreatmentmodels• YoucanreferclientsforintensiveworkinEGALAtherapy• YoucanrefertoanEMDRorSEtherapistconcurrentwithyourtreatment• Youcanassistclientswithgettingaserviceanimal

Remember

• Researchconsistentlyshowsthetherapeuticalliancebetweenclientandtherapististhesinglemostimportantfactorinhealing

• “Theemergingpicturesuggeststhatthequalityoftheclient–therapistallianceisareliablepredictorofpositiveclinicaloutcomeindependentofthevarietyofpsychotherapyapproachesandoutcomemeasures.”

Remember

• YouareaconduitofGod’shealingpower

• Bringingthehealingpoweroftheholyspiritintotreatmentisacriticalcomponent–regardlessoftechniquesormodalitiesused

Institute for Compassionate Care

www.institute4compassionatecare.com

YouTubeChannelLiveLiveVideo:EllersFamily

jscisney@gmail.com