What to do when pain never ends

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1What to do when pain never endsLillieth Grand, M.S. MT-BC

WRAMTA Conference 20112Framework:client as subject matter expert, therapist as support

The therapist supports, the client guides.In the client - therapist dyad, the therapist mirrors and absorbs the client's pain3Overview 1ResiliencyCase examplesPositive outcomes versus acknowledging what cannot be changed4Overview 2Structure 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 " .

5Resiliency

6Resiliency, a biochemical storyCharles 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 Y7High cortisol high dissociation

8Resiliency, continued

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

9Resiliency, continued 2Salimpoor, V.N., Anatomically distinct dopamine release during anticipation and experience of peak emotion to music, Nature Neuroscience Jan. 2011Intense pleasure in response to music can lead to dopamine release in the striatal system.Anticipation of an abstract reward can result in dopamine release.10Significant [11C]raclopride binding potential (BP) decreases during pleasurable compared with neutral music listening indicating increased dopamine release during pleasurable music

11Number of chills reportedpositively correlated with percent binding potential change in the caudateconsistent 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.

12Resiliency, continued 3Bonanno, George A.,The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss, Basic Books, 2009After six months, less than 10%of people affected by a catastrophic event continued to experience trauma symptoms13Resiliency, continued 4Wellbeing: Tom Rath, Jim Harter, Gallup Institute: positive defaults

Career, Social, Financial, Physical, Communityhttp://www.wbfinder.com/home.aspx14Case examplesVicarious traumatization: Critical Incident Stress ManagementLegacy Song: Transitional Object15Positive outcomes versus acknowledging what cannot be changed - 1, DiscussDavid J. Berghus, Arthur E. Jongsma, Family Therapy Progress Notes Planner: Client PresentationAccidental Sudden Death - Family members have begun to process their griefLoss of Pregnancy - As treatment has progressed, the parents have moved through the stages of grief16Positive outcomes versus acknowledging what cannot be changed - 2, DiscussDeath 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 deathDeath Due to An Acute Illness - As treatment has progressed, the family has begun to cope with the loss of the childTrauma 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 child17Positive outcomes versus acknowledging what cannot be changed - 3, DiscussChanging Family Dynamics - The family has begun to function again in a more stable manner after the loss of the childOverprotectiveness of Survivors - As treatment has progressed, the parents have demonstrated a healthy level of protection and concern for the surviving children18Positive outcomes versus acknowledging what cannot be changed - 4, DiscussInterventions:Allow Venting of Grief - The family was supported and encouraged as they shared feelings of grief and pain associated with their lossPromote Unity - Family members were assisted in promoting a sense of unity among each other19Positive outcomes versus acknowledging what cannot be changed - 5, DiscussShare images / share songs - an emphasis was placed on the sharing of memories of the deceased to keep that person alive in spiritDiscuss circumstances of death - Family members were supported when describing the details of the child's death Legacy Song20Positive outcomes versus acknowledging what cannot be changed - 6, DiscussEmphasize deceased living within - Family members were supported to recognize the characteristics of the deceased within each otherObject of transition - find and sustain presencePrepare: find your resiliency song and apply it to recurring stressors21Positive outcomes versus acknowledging what cannot be changed - 7, DiscussUse pleasurable (meaningful) songs as behavior change cuesAction "Pull Yourself Up" SongReflection "Good bye" SongsExpression "Love" Songs22Viewpoints - Self PsychologyReflective PracticeReflective Supervision23Viewpoints - Behavioral -1R Rosser, S Dewar, Department of Psychiatry, University College and Middlesex School of Medicine, Journal of the Royal Society of Medicine Volume 84 January 1991Work with montage including songs , develop personal diaries and artistic material representing the experience and subsequent reactions. 24Viewpoints - Behavioral -2Rose 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 4Experiencing, avoidance and hyperarousal, Compassion Fatigue and vicarious traumatization Attend sufficient training25Viewpoints - Behavioral -3Therapist 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 clientTeach client to maintain spiritual contact with deceased26Viewpoints - Behavioral -4Conduct assessment based on Holmes - Rahe - Life - Stress InventoryConduct assessment based on Child Trauma Academy trauma interview Teach Lessons based on trauma assessment: www.childtraumaacademy.com27Structure a treatment plan and dischargeCreate a life montage - before and after traumatic eventTherapeutic journal and therapeutic discussionPotential re-enactmentWork towards Family Therapy Progress Notes Planner benchmarks, set becnhmarks in partnership with the consumerReceiving and giving gifts: conduct a risk benefit analysis28Roundtable"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 " 29"never tear down a wall if you don't know why it was built"Circle Of Security: " The worst danger isnt that children experience fear. The worst danger comes when fear is not recognized and accepted by a safe and secure caregiver. A childs sense of fear, when it is unattended to by a caregiver, moves in the direction of terror. The childs 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 doesnt feel like they can be shared with and organized by someone who is bigger, stronger, wiser, and kind." 30"never tear down a wall if you don't know why it was built" - 2COS: " 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." 31Q + Aroundtable32