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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)
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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
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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
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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
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A-TIP Overview
• ATIP/CIDslidefromRoy#19in4hour
A-TIP Acute Traumatic Incident Processing
CID Ground
Stabilize
Refer
Crisis
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• 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
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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.”
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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.
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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
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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
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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
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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
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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
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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
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