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Stress Stress is the outcome of a cognitive process in which a challenge or threat is perceived, the ability to control is assessed, in if the individual cannot cope, helplessness is registered [Benner, 1997: 32]. Lazarus in Benner [1997: 32] argued that stress consists of three processes: • • • primary appraisal - is it a threat to oneself? secondary appraisal - potential response to threat coping - executing the response.

Seligman states that when an individual perceives no control over events, or lacks efficient coping responses, helplessness and depression will result. Problem-focused-coping has been found to be more effective: • • • positive reinterpretation seeking support planning

Avoidance and disengagement do not solve anything: • • • • suppressing thoughts using worry or punishment to suppress memories giving up denial

Cognitive processing • Cognitive bias: people with ASD exaggerate the probability of future negative events

2 • • Attributions: shame and anger at self and others; attribution of responsibility to others Perception of death threat in accident survivors determines future ability to recover Biology Elevated arousal becomes conditioned with fear and the traumatic experience. Cortisol is protective in the face of stress. Cortisol levels are generally lower [Benner, 1997: 35] and the hypothalamic-pituitary-adrenal axis may dysfunction. Loss The survivor of trauma may experience loss in the form of: • • • • • • • Pain • • • Whiplash injury traffic accidents accidental injuries injury loss of mobility or a limb loss of memory or cognitive capacity [brain injuries] separation/death of significant others destruction of social networks/relocation employment home/relocation

In summary

3 • • • Most people do not develop PTSD after a critical incident. Most will recover [symptoms disappear within the first week] If the individual has ASD symptoms during the first week, chances are they will develop PTSD if they do not have good treatment. Relationships, problem solving and, communication skills and the ability to solve conflict may deteriorate as stress increases [Giarratano, 2004: 46]. • • • During problem solving, attention should be given to negotiating goals, rules, routines and adaptability to stress. Keep interpersonal roles hierarchical functioning, distribution of power and subsystem boundaries stable. Tone and range of feelings, involvements/attachment/commitment, respect and regard should be monitored. ICD-10 diagnosis of Acute Stress Reaction: • • • • • • • • generalized anxiety withdrawal narrowing of attention apparent disorientation anger or verbal aggression despair or hopelessness overactivity excessive grief [Giarratano, 2004: 5-6]

Combat stress reaction • • • restlessness/irritability psychological withdrawal constriction of affect

flashbacks. dehydration loss isolation dehumanisation exposure to the grotesque disturbingly incongruent events B . not real. PTSD = 1] dreams. starvation. thoughts. irritability] D marked avoidance [ASD = 1. activities. occupational or other important areas of functioning E F . recurrent images.expose to traumatic event . extreme physiological strain = pain. a sense of reliving the experience. people] causes clinically significant distress or impairment in social. illusions. far away/fog] + depersonalisation [not in their body] + dissociative amnesia [inability to recall important aspect of trauma/gaps in memory] C traumatic event is persistently re-experienced [ASD=1.while or after experiencing distressing event. concentrate one detail] + derealisation [dream. exaggerated startle response. irritability. witnessed or confronted with event[s] that involved actual or threatened death/ serious injury. feelings. places.4 • • • • • • • • • startle reactions nausea/vomiting/abdominal pains paranoid reactions psychomotor retardation/apathy sympathetic activity confusion aggressive or hostile behaviours anxiety or depression ill-concealed tearfulness [Solomon & Mikulincer in Giarratano. PTSD = 3] of stimuli that arouse recollections of the trauma [thoughts. poor concentration. detachment or absence of emotional responsiveness [freeze] + reduction in awareness of his/her surroundings [confused. time slow/stop. or a threat to the physical integrity of self/others . hypervigilence. individual has 3 or more of the following dissociative symptoms: + subjective sense of numbing.experienced. motor restlessness] [anger. conversations. PTSD = 2]: marked symptoms of anxiety or increased arousal [difficulty sleeping. helplessness or horror examples: threat. movie.response involved intense fear. 2004: 6] DSM-IV: Acute stress disorder/PTSD A . or distress upon exposure to reminders of traumatic event hyperarousal [ASD = 1.

anger anger management . assault Two Worlds Model. moods.‘it was my fault’ .past and present .nightmares psycho-education exposure therapy cognitive restructuring 1BEHAVIOURS .negative thoughts/beliefs/images .re-experience . max 4 weeks. thoughts.fear .relationship .job .stomach upsets . physical reactions and behaviour are all interconnected 1ENVIRONMENT .5 G 1ASD: minimum 2 days.past learning experiences .medication . impact on NOW world 1PHYSICAL REACTIONS .anxiety .memories .negative self-statements .increased fighting .increased crying .distressing emotions .witness accident.nausea arousal reduction THOUGHTS MOODS = emotions .‘we are not safe’ . occurs within 4 weeks of traumatic incident PTSD: can only be diagnosed 4 weeks after traumatic incident H 1not because of medication/drug of abuse or general medical condition CBT MAP Environment.

6 in vivo exposure therapy before/during/after strategy .

of structure. Investigate what happened immediately before a problem behaviour or situation. care of children.Before/During/After technique 1Before/During/After technique Determine situational triggers and reinforcing consequences like self-harm.long-term consequences . BEFORE = potential triggers What happened immediately before the problem? What were you doing? Describe the event step-by-step What did you feel? Where did this occur? Who else was there? DURING = problem behaviour Who did what during the situation? . list what happened . sadness. the result and what the individual did afterwards or what followed. not judgements.How did you feel when it was all over? INTERVENTIONS INTERVENTIONS INTERVENTIONS . self-devaluation] inability to enjoy rewarding interaction with others/inability to be helped Where do I begin? • • • • Introduce some degree of order. anger] negative self-perception [self-accusation.Summarize the result .7 1Signs that you need help • • • • impaired task performance [work. of direction [to counter loss of control] Prioritize Get rid of the mess .keep observable .What did you do/say? AFTER = reinforcing elements What happened immediately after/ .techniques .CBT map .keep to facts.complete first . bingeing and fighting.raw emotion: fear/anger/irritability Break problems down into manageable units .short-term consequences? . getting help] poorly modulated emotions [fear.

civilians speak rubbish [emotional distance] .blame others for causing the reaction .ground yourself in now and present sensations . .make sure you are safe GAINING DISTANCE [Leahy in a realistic human . someone dies ..Anyone could be the enemy NOW WORLD .look at facts .balanced view of self .sex is pain/power/dirty [sexual assault] .I am an object to be used [sexual abuse] .nobody is perfect . non-evaluative language. imagine yourself disappearing altogether. visualize them on a white board and deal with them. choose how you will react .allow yourself to experience life now . Imagine yourself to be a grain of sand on a beach blown into the distance by a gust of wind.I can’t let my guard down .Get to the present by describing what is around you in concrete. Imagine the situations.late means dead [anger/rage/panic] ..Try also to take any evaluation out of any thoughts that crop up. Seeing negative thoughts on a white board You may find it very helpful to write up negative thoughts on a white board. it makes it much more clear that they are negative.8 Two-worlds model of PTSD Having PTSD is like living in two worlds at the same time: the TRAUMA world and the NOW world. indeed the universe.Finally.what is your definition today . ..If I make a mistake. .Gain distance from your worrying thoughts by saying out loud or writing down “I am having the thought that” and “I am noticing that I am feeling .mistakes equal death . The aim is to get the individual back to the NOW world.” Let the chain of thoughts and feelings run on as long as it wants.take responsibility. When you have negative thoughts again. . TRAUMA WORLD . The rules may or law may be different in each of the worlds.. . going on without you. 2008: 81] Suggestion: Flowing through you like a river .Think again about the situations that evoked worrying thoughts and imagine yourself out of these situations.

1The TRAP Model T Trance R Reexperiencing A Avoidance P Physical tension .Remember being assertive and saying ‘no’ to additional work. wash your hands and give yourself time to calm down and solve problems constructively. The loo as a behavioural escape . go to the bathroom.If you are in a difficult situation.9 Hearing the therapist’s voice .

selfexposure esteem grounding .arousal reduction withdrawal strategies .reduce confusion hierarchy of fears .Dissociation ➄ .empower .ID and challenge of avoidance in common cognitive maintaining distortions anxiety black and white rationale for thinking Cognitive exposure catastrophizing restructuring concepts of selective attention .assist techniques family/reintegratio distraction n exercises de-condition wrong visualization associations of anger danger/ reduce management pathological fears medication .improve attention desensitisation. flashbacks and nightmares using exposure therapy] .integrate fragmented sensory and affective info to create a traumarelated narrative .assist family setting and Trap model monitoring in vivo Two worlds tasks ➀ reducing difficulty Crisis = graded management exposure. imaginal .reduce reexperiencing . the role . ➁ motivation generalisation.daily event scheduling ➂ Arousal reduction= increase self[in vivo exposure] control and social .instill hope esteem distress scale . .restructure irrational beliefs .psychophysical exercise education.increase habituation. Psychoeducation .manage crisis rehearsal . hyperventilation motivation.treatment prioritization Cognitive before/during/after restructuring ➃ Targeting avoidance .increase feelings breathing control of self-efficacy.Treat with Targeting reexposure therapies experiencing symptoms [intrusive thoughts and images.improve selfextinction .10 .reduce depression .

more aware of safe environment SIMPLE TIPS FOR DISTRACTION . The following techniques may be used: • • • Isometric exercises = tension/release exercises Self-safe hypnosis .take your mind off thoughts . panic] Simple tips for distraction SELF-SAFE HYPNOSIS . They will then realize that they are safe and can relax. relaxation .grounding technique [flashbacks. intrusive thoughts ISOMETRIC EXERCISES .11 Grounding and distraction techniques Grounding techniques work by having the person focus upon the physical sensations in and around their bodies.helps for fears. worries.

boy plays with it. consequence negative. what it feels to touch/smell/taste it .reward. will repeat action .observe what is happening around you . what would it smell like .look at a painting on the wall imagine who painted it.repeat with legs strait out in front of you . pets.count forward by 3/4/5 .look at the people and imagine what houses they live in. . fear. busy painting it.12 Look around you and say: 5 things you see around you 5 things you can hear 5 things you can feel touching your body Then say: 4 things you can see 4 things you can hear 4 things you can feel Then go down to 3/2/1 thing(s) you can see/hear/feel Say them aloud/in a whisper/in your mind . bell + salivate]. knees bent . people often experience high levels of fear. stretching your calves Try progressive muscle relaxation [see Multiple Stressor].try to recall lists (name of a food/name that starts with a/b/c/d/e/f . time of day. from corner to corner (eyes open or closed) Pick one muscle group. noises and smells will later elicit the same fear. white cotton ball. white rat.tense your leg muscles by raising your feet off the floor. flexing your chest muscles .try to guess how old it is. When exposed to a life threatening situation. relax and breathe your arms back into the sides of the chair press your palms down on the arms of the chair .look at an object close to you . 1Classical conditioning Also called associative learning .when one learns to associate one thing with another. beard of Santa Claus].trace the room by describing everything you see. kind of underwear they have on . imagine yourself inside the painting. Stimuli associated with the original your feet down into the floor . tense it. usually because they occur together [dogs + bell + food. rabbit. who made your palms together in front of you. boy touches it + loud noise.put your arms behind your back and clasp your hands together . Sitting down . what cars they drive. no fear. later generalizes to similar white objects. touching things in the painting. Generalization: Fear and anxiety can also generalize to other objects [white rat.join your hands behind your back and stretch backwards . walking around. Operant conditioning Also known as learning by consequences of action [consequence positive.stand on tiptoe .push your shoulders/back into the chair Standing up .crouch down slightly. the place. breathe in and count to 5. will refrain from action punishment].

least frightening to most frightening imaginal desensitization: relax + visualization • • • in-vivo exposure: real life .exposure alone causes desensitization Subjective units of distress scale A measure of self-reported distress levels 0 ☺ Lowe st rati ng of distr ess 1 2 3 4 5 ❍ midd le 6 7 8 9 10 ☹ High est ratin g of distr ess Habituation .13 In-vivo exposure therapy Consists of: • reciprocal inhibition: fear + opposite: relaxation systematic desensitization: stimuli presented in graded way .

Altering irrational thoughts about the event Use expose therapy if reasoning does not help. Desensitisation If a non-dangerous situation that has been avoided is faced. 2004: 175].it is difficult to put the experience into words. No more fear. the less fragmented the memory is [Giarratano. Integration of fragmented information Overwhelmingly distressing information can get split [sensory or emotional fragments] during disassociation. That is why some people find it difficult to speak fluently about the event . in detail . desensitisation will occur [many trials]. derealisation and personality integrate various aspects of the experience . depersonalisation. They persist in the form of flashbacks and memory fragments associated with the original traumatic event.14 Anxiety levels drops [one trial] over a period of time. The more articulate. habituation will occur.until desensitisation occurs . General principles The EAS practitioner/professional assists the patient to generate a narrative [to tell the story] of the traumatic memory/event: • Recount the story verbally. If it is repeated enough times.

unable to cooperate . What did you feel?/What were you thinking?/What did you smell/hear/see? Rate distress.15 • Write it down in a journal/record the story on an audiotape/videotape. Progress is made when PROGRESS NEED TO IMPROVE .therapist reads script Next • • • • Continue until distress is low. Use a letter writing task when loss or death is involved.script is written out on paper or recorded . Continue in vivo exposure until habituation occurs. Make notes of additional information. what does this memory make you think about you? Is this belief true? Review the script/journal/recording.past tense used .whole memory .high sensory detail .relaxation . additional details are recorded • • • • Ask yourself.low sensory detail . Repeat until at least a 50% reduction in distress has occurred. every time this is done. Challenge negative self-statements and distortions of facts.memory is broken into a graded hierarchy .no relaxation .patient or therapist reads script . Concentrate on ‘hot spots’. .present tense used .

1. should. Are you thinking in all-or-none terms? Are you using words or phrases that are extreme or exaggerated [always. 3.1CHALLENGING QUESTIONS 16 Below is a list of questions to be used in helping you challenge maladaptive or problematic beliefs. 8. Are you taking the situation out of context and only focusing on one aspect of the event? 7. need. Is your belief a habit or based on facts? Are your interpretations of the situation too far removed from reality to be accurate? 4. Is the source of information reliable? Are you confusing a low probability with a high probability? . must. forever. 5. Belief: _____________________________________________________I don’t deserve to have a family. What is the evidence for and against the idea. can’t. every time]? 6. Answer as many questions as you can for the belief you have chosen to challenge. never. FOR:_________________________________________________________________________ ______ AGAINST:____________________________________________________________________ ________ 2.

Life stress is the fire. Therapy improves problem solving.17 9.Guilford Press: New York. P A.trauma creates a messy filing cabinet. 206]. but corrective action was not incorporated. some of the memories will spill over from time to time. Are your judgements based on feelings rather than facts? Are you focused on irrelevant factors? [101] [Resnick. C M & Rizvi. 2008. Monson. the less the ladder burns. The memory has been activated. and that assists coping. Distressing dreams often provoke people to wake up in fear. extracting a tooth.trauma work digests the memory. climbing out of hell on an aluminium ladder. One can also compare lancing a boil. pp65-122] Motivating clients Exposure therapy is like a Bunsen burner used in science class. D H. wanting to come inside the house. Working with traumatic nightmares • • Perhaps dreaming is an associative process that helps us to make sense of intense experiences in our lives. but change the ending. allowing the survivor to feel comfortable again [Giarratano. Think of your nightmare. Posttraumatic Stress Disorder in Barlow. a wet. Clinical Handbook of psychological Disorders. With the fire on high. the further you climb. Trauma memory work is like a tap. muddy dog out in a storm. undigested meal . 2004. to let them out [distress] under controlled and safe circumstances. 10. • • many nightmares are not exact representations of the trauma. Repetitive dreams can be targeted using the following methods: . Traumatic memories are inside the glass container with a lid on top to keep them all in. or the brain as a filing cabinet .

splash your face with water and get back into bed.create a script for the nightmare Change the images/ending of the nightmare towards themes of mastery and control [overpower attacker. • For general insomnia: use sleep hygiene methods. changes real gun into a toy gun]. eliminate learned sleep-preventing associations.18 • • Use prolonged exposure to the traumatic memory itself . then rehearse it with the object or skill present [speed or strength to escape. COGNITIVE THERAPY Behaviours and emotions are linked to thinking . as it influences serotonin levels and the amygdala [REM sleep. Use cognitive restructuring to identify and change beliefs and behaviours that interfere with sleep. The stage of sleep and the nightmare will then be disrupted. Sleep cycle interruption: A partner. Get out of bed. • Find out what is missing from the nightmare. arousal states]. • • EDMR [Eye Movement Desensitisation and Reprocessing] will use eye movements to target the nightmare. having the weapon needed] • SSRIs [fluvoxamine] improves sleep quality and reduces nightmares. friend or alarm clock wakes you 30 minutes before the nightmare typically occurs. and restrict your sleep to specific hours every night.

Thinking requires attributing meaning to those things we pay attention to. B beliefs thoughts interpretations C consequences emotions behaviour physiology/physical reactions I tell myself something it is a bullet/danger I am . .. it will be ignored or just observed. Interpretation of our experience creates our response [half a glass of water . If it is not relevant. An individual only responds to that which is important for him. I don’t deserve I feel something feels shocked and fearful swerves off road.19 A Actual event. Trauma and cognitive schemata • Past experiences and learning form filters so that we selectively attend to information that matches our beliefs.half empty].half full .learning creates automatic responses [stopping at a red light. Prior learning can shape our responses .. driving a car] and habits.. external reality events people places things something happens rock hits windscreen I killed .. guilt • • • • • Thoughts usually come before feelings and action.. ducks heart pounding anger.

trust in relationships and confidence about the future. • Negative core beliefs may develop.20 • Trauma shatters beliefs about invulnerability .. This may evoke uncertainty and helplessness.the world is no longer safe. disrupt inner security. It is all my fault I I I I I am am am am am weak gutless an animal dirty nothing 1Common cognitive distortions .. Negative interpretation of distressing events The following themes have been identified: CONTROL I am out of control I am helpless RESPONSIBILITY/GUILT VULNERABILITY I m going to die I am exposed I am not safe anywhere anymore SELF-ESTEEM I did not do enough I should have done more What if I had .

act as if prediction is a fact I feel it. noone. everything.expect punishment. right/wrong = magnification/exaggerating or Catastrophising always. exaggerate worst outcomes. you will be hurt by people feel incompetent. so it must be true I feel it. witness . everyone. total failure shows a need for control as this was lost during trauma jumping to conclusions. never. so there must be a reason should. you feel anger. ought . unlovable time I will be killed]. irritation. nothing. ignore positive [often feel betrayed] world is unfair. must.21 Black and white thinking = all or nothing thinking oversimplify = good/bad.exaggerate importance of things . evidence is lacking or contradictory . resentment overgeneralization mental filter disqualifying the positive jumping to conclusions emotional reasoning should statements . does not count no facts to support as in mind reading or the fortune teller error . challenge a single event is a never-ending pattern of defeat focus one negative detail reject anything positive. assuming the worst.shrink things until they appear tiny minimalisation/minimizing Selective attention disregard important aspects of a situation focus on negative. guilt when you direct these statements to others. no facts to support [bank robbery.

22 labelling and mislabelling extreme form of overgeneralisation instead of describing your new perspective TWO WORLDS Imagine best friend was in same situation.louse you see yourself as the cause of some external event assume people are thinking negatively when there is no definite evidence personalisation MIND READING Challenge beliefs by using • • • • literal challenge best friend two worlds evidence for/against LITERAL CHALLENGE BEST FRIEND CHALLENGE literally define the word you are using generate extreme examples review your statement about yourself .I am a murderer .no premeditation .generate extreme examples using other people .someone who deliberately sets out to kill someone . and did exactly what you statement . Imagine what a third person would comment What would you say to this person about your friend? Use same standard for yourself COGNITIVE CHALLENGE Compare trauma world to now world Self care to prevent burnout Use evidence for or against .loser or another person .do you fit . you give yourself a label .

Confidence diminishes. erosion of idealism and lack of achievement. .Burnout is a process which becomes progressively worse because of job The ability to make decisions declines. Black and white thinking is often used by perfectionists with high standards. 23 strain.

24 Symptoms of burnout PHYSICa L EMOTIONA L BEHAVIOUR INTERPERSONA L WORK ❏insomnia ❏fatigue/ph ysical exhaustion somatic problems [headaches flu symptoms stomach upsets anxiety ❏irritability anger resentment ❏anxiety ❏depression ❏guilt blame ❏sense of helplessness ❏fear it won’t get better ❏fear losing control ❏aggression ❏callousness ❏pessimism ❏defensivenes s ❏substance abuse ❏indifference ❏selfpreoccupation ❏resistance to change ❏rigid thinking ❏conflict ❏tunnel vision ❏withdrawal from clients and coworkers ❏difficulty communicating ❏inability to concentrate ❏poor work performan ce ❏absente eism ❏quitting the job ❏misuse of work breaks ❏high resistance to going to work every day ❏clock watching .

make time for meals. facials. colleagues. no skipping meals or eating on the go. substance abuse/misuse. watch out for over/under eating ❏schedule time for fun ❏schedule time for vacations ❏assertiveness training.priorities organise ❏set realistic goals PROFESSIONAL INTERPERSONAL ❏Increase social supports .25 1Strategies for preventing burnout PHYSICAL SKILL DEVELOPMENT ❏exercise ❏body nurturance [massages. hypnosis. learning to say no ❏look after yourself before you look after others ❏stress management . friends and children . taking calls at home ❏Watch out for being cynical and bitter ❏Personal boundaries ❏Know your limits ❏Plan for emergencies .they offer hope and joy ❏Get help when you need it. yoga] ❏adequate sleep ❏eating properly. yoga ❏cognitive restructuring you have people who will listen without criticising? Who can give honest an outlet for frustration ❏Balance .too many responsibilities. child abuse . Build in regular time with your loved ones.domestic violence. ❏Get involved with your community . home ❏Boundaries/set limits ❏Time boundaries ❏Refrain from overworking . See this as a sign of strength. regular overtime.distorted thinking ❏time management .social activism . taking work home. warm baths.

homework . exploring.write an impact statement . music ❏Self-awareness . 2007: 103-105 . play. 2002: 66]] SESSION 1. paint. hobbies. Street & Resick.treatment rationale . 2004: 260.reduce stress. cooking.know when you need help ❏Humour .write. learning ❏Relaxation/meditation ❏Contact with nature ❏Play with your pets ❏Creative expression .provide overview of treatment .explain symptoms of PTSD in terms of CBT .five-minute account of the trauma [worst one] . thinking. wandering. any form of art. gain perspective ❏Make time for dreaming. dancing. planning and being in touch with your dreams [Giarratano. Greenstone & Leviton.26 PSYCHOLOGICAL ❏Life balance . hobbies. INTRODUCTION AND EDUCATION Shepherd.

Homework .complete ABC sheets daily SESSION 3.homework .27 SESSION 2. ID THOUGHTS AND FEELINGS .discuss the meaning of the impact statement . further differentiating between thoughts and feelings Label thoughts v feelings Recognise that changing thoughts can change the intensity of types of feelings Begin challenging self-blame and guilt with Socratic questions .review concepts from the first session .changing beliefs to incorporate the trauma .introduce the ABC sheet .help ID and see the connections between events. with sensory details and read daily .fill out the ABC sheet together . feelings and behaviour .complete ABC sheets to become aware of connection between events.changing memories to fit beliefs Overacommodation overgeneralizing beliefs as a result of memories Accommodation .write a trauma ABC the impact statement. THE MEANING OF THE EVENT . begin to ID stuck points . thoughts.ID: Assimilation . thoughts and feelings .

encourage affect .notice and record examples of faulty thinking patterns on the challenging beliefs worksheet SESSION 5. start with self-blame . discuss new details that emerge . CHALLENGING QUESTIONS .rewrite the trauma account.continue cognitive therapy re stuck points .challenge stuck points of selfblame and other forms of assimilation using Socratic questions .involve the client in challenging assumptions and conclusions that the client has made after processing affect. focus on self-blame and assimilation .homework .read the second trauma account aloud. complete ABC sheets daily .homework .review challenging questions sheet to address stuck point.introduce the faulty thinking patterns sheet .introduce the challenging questions sheet to help ID stuck points .challenge at least one stuck point a day . REMEMBERING THE TRAUMA . ID STUCK POINTS SESSION the traumatic account aloud.28 SESSION 4.homework .ID stuck points .

one relating to power/control.identify stuck points every day. FAULTY THINKING PATTERNS .power/control issues related to self and others . go over the module on safety .review the challenging beliefs worksheet to challenge stuck points of trust. generate alternative beliefs . SAFETY ISSUES SESSION the challenging beliefs worksheet to address safety and other relevant stuck points .homework . confront them using the challenging beliefs worksheet SESSION 8. use the trust module on the challenging beliefs worksheet . and challenge them using the challenging beliefs worksheet .ID stuck points. one relating to trust. and confront them using the challenging beliefs worksheet . TRUST ISSUES .homework .introduce the challenging beliefs worksheet with a trauma example .introduce second of five problem areas: trust issues related to self and others. one relating to safety.introduce the first of five problem areas: safety issues related to self and others.29 SESSION 7.client to identify stuck points every day.homework .help the client confront faulty cognitions using the challenging beliefs worksheet and generate alternative beliefs .introduce the third of five problem areas .review the faulty thinking patterns sheet to address trauma-related stuck points .

ID stuck points. one relating to esteem a nice thing for the self at least once per day .continue to do at least one nice thing for the self each day SESSION 11.discuss the connection between power/control and self-blame. ESTEEM ISSUES .introduce the identifying assumption sheet IAS and determine which assumptions are applicable to client .practice giving and receiving compliments daily . challenge them using CBW .introduce the fourth of five problem areas . challenge stuck points using the CBW .30 SESSION 10.esteem issues related to self and others Review the esteem module Explore the client’s self-esteem before the traumatic event . challenge them using CBW .rewrite the impact statement .discuss the client’s reactions to giving and receiving compliments and doing nice things for oneself . using CBW .ID stuck points daily.continue to give and receive compliments .homework .confront assumptions checked on the client identify esteem issues and assumptions.introduce the fifth of five problem areas: intimacy issues related to self and others . challenge using CBW . one of which relates to intimacy issues.homework . POWER/CONTROL ISSUES .

INTIMACY ISSUES .remind the client that he/she is taking over as his/her own therapist now and should continue to use the skills learned 1SOCRATIC QUESTIONS: • 1What do you mean when you say x? o o o o o o o o o o o o o o o What is the evidence that x is true? What is the evidence against x being true? What might be the worst that could happen? What leads you to think that x might happen? And if that happened. as well as any remaining stuck points.31 SESSION 12. what then? If that did happen.have the client read the new impact statement .help the client identify goals for the future and delineate strategies for meeting them . challenge using CBW . How would that work in your body? Is there an alternative explanation? Is there any other way of seeing the situation? What are the advantages/disadvantages of thinking that? Is it helpful or unhelpful? .involve the client in reviewing the course of treatment and his/her progress .help the client identify intimacy issues and assumptions. what would you do? How would you cope? Have you been in similar situations in the past? How did you cope then? How does thinking that make you feel? Are you thinking in a biased way? Are you predicting the future or mind reading? Are you paying attention only to one aspect? What if you looked at it from a different angle? What would you say to a friend who kept on saying x to him/herself? “I am stupid/I am terrible”.

2007:109] What is the evidence for/against this idea? For Against Are you confusing habit with fact? Are your interpretations of the situation too far removed from reality to be accurate? Are you thinking in all-or-none terms? .. I TELL MYSELF SOMETHING Behaviour What happened C... I FEEL ..32 o o o o o o o o What would it mean to you to see things differently? Are you making decisions based on your feelings. SOMETHING HAPPENS Antecedent What happened before . or is reality telling you something different? What might you tell a friend in this situation? What would your friend say to you? Is there something else you could say to yourself that might be more helpful? What do you think you could change to make things better for you? How would you like things to be different? What would you like to do instead? • .. I was abused I was told bad things about myself B. Consequences What happened after . Angry at myself I feel ashamed of myself I must be bad I am stupid and ugly 1CHALLENGING QUESTIONS SHEET [Follette & Ruzek. 2008: 60] 1ABC SHEET A.What would have to happen to make it possible? [Wills..

1Exaggerating or minimizing the meaning of an event [you blow things way out of proportion or shrink their importance inappropriately]. Think about how that pattern affects you. 1Disregarding important aspects of a situation . Is the source of information reliable? Are you thinking in terms of certainties instead of probabilities? Are you confusing a low probability with a high probability? Are your judgements based on feelings rather than facts? 1Are you focusing on irrelevant factors? 1FAULTY THINKING PATTERNS SHEET: Considering your own stuck points.33 Are you using words or phrases that are extreme or exaggerated always. I do not want to make the call because I do not have time. need. Drawing conclusions when evidence is lacking or even contradictory. every time? Are you taking selected examples out of context? 1Are you making excuses? I am not afraid . must. Write in the stuck point under the appropriate pattern and describe how it fits that pattern. find examples for each of these patterns. forever. should. never. can’t.I just do not want to get out. Other people expect me to be perfect.

1Overgeneralize from a single incident [you view a negative event as a neverending pattern] 1Mind reading .assuming that something you feel strongly must be true 1COLUM NA Situatio n COLUM NB Automa tic Thought s COLUMN C Challenging your automatic thoughts COLUMN D Faulty thinking patterns COLUM NE Alternat ive thought s COLUMN F De= catastrop hizing .34 Oversimplifying events or beliefs as good/bad or right/ reason based on how you feel .you assume people are thinking negatively of you when there is no definite evidence for this 1Emotional reasoning .

Rate belief in alternativ e thoughts from 0100% What is the worst that could ever realistically happen? evidence habit/fact interpretations not accurate all or none extreme/exagg erated out of context source reliable probability H/L feelings/facts Even if that happened. Jumping to conclusions exaggerate/mi nimize disregard important aspects oversimplify overgeneralize mind reading emotional reasoning What else can you say instead of what you have written in Column B? How else can you interpret the event instead of what you have written in Column from substances. The main aim is to create safety . angry etc and rate the degree to which you feel each emotion from 0100% irrelevant factors 1OUTCOME Rerate belief in automatic thoughts in Column B from 0-100% Specify and rate subsequent emotions from 0-100% 1The following 25 topics have been developed for support groups. what could you do? 1EMOTIO NS Specify sad. safety from dangerous relationships [domestic violence and drug-using friends] and safety from .35 1Describe the events/ thoughts or beliefs leading to the unpleasan t emotions Write the automatic thoughts that precede the emotions in Column A Rate belief in each automatic thought from 0100% Use the Challenging Question Sheet to examine your automatic thoughts from Column B Use the Faulty Thinking Patterns Sheet to examine your automatic thoughts from Column B.

each will receive a handout .integrating the split self .asking for help .few minutes .taking back your power . Seeking Safety is an integrated approach for trauma. “What is the main point of the quotation?” and links it to the topic of the session .when substances control you .extreme symptoms [dissociation and self-harm].respecting your time .healthy relationships .answer two questions: Name one thing you got from today’s session? .recovery thinking .discovery COMBINATION TOPICS .report on 5 questions: How are you feeling? What good coping have you done? Any substance use/unsafe behaviour? Did you complete your commitment? Community Resource update .rehearse new skills CHECK-OUT .facilitator or clients select any of the 25 topics .termination 36 1SESSION FORMAT CHECK-IN QUOTATION RELATE THE TOPIC TO THE CLIENTS’ LIVES .red and green flags .coping with triggers .detaching from emotional pain grounding .What community resource will you call? .getting others to support your recovery BEHAVIOURAL TOPICS .a client reads the quotation out loud .facilitator summarizes main points .to help emotionally engage clients .compassion .setting boundaries in relationships .creating meaning .healing from anger .give facilitator feedback .each topic represents a safe coping skill .PTSD .commitment .self-nurturing COGNITIVE TOPICS .safety .find out how the clients are doing max 5 min per client .community resources .30-40 minutes .honesty .facilitator asks.introduction to treatment/case management .What is your new commitment? .the life choices game . PTSD and substance use disorder.connect topic to lives . 1INTERPERSONAL TOPICS 1.taking good care of yourself .reinforce progress .

members report on weekly tasks and outcomes.majority of group time SESSION TITLES INTRODUCTORY SESSIONS 1 2 3 INTRODUCTIONS.members express feelings.facilitators explain homework task and rationale. STRUCTURE. answer questions. and readiness to engage in group . shape homework compliance and performance. help plan for next week.37 1CORE ELEMENTS: TRAUMA FOCUS GROUP CHECK-IN . facilitators calm distressed members. concerns. facilitators collect homework. GROUP RULES PTSD EDUCATION COPING RESOURCES REVIEW OF HOMEWOR K SPECIFIC TOPICS ASSIGNME NT OF HOMEWOR K 1CHECKOUT 4 5 NEGATIVE AND POSITIVE COPING PTSD AND SELF-CONTROL PRE [MILITARY] AUTOBIOGRAPHIES PRE-WARZONE MILITARY AUTOBIOGRAPHIES . TRAUMA FOCUS SESSIONS 9-10 11-22 TRAUMA SCENE ID/COPING REVIEW TRAUMA EXPOSURE AND COGNITIVE RESTRUCTURING RELAPSE PREVENTION AND TERMINATION 23 24 25-26 27-28 29 INTEGRATING TRAUMA: 3-WAY MIRROR IMPROVING SOCIAL SUPPORT ANGER MANAGEMENT RISK SITUATIONS AND COPING STRATEGIES BEHAVIOURAL CONTRACTING . and problemsolve obstacles to its completion .follows session outline .members express reactions to sessions. and explore obstacles to completion 6-7 8 . or reinforce individual change.

communication guidelines: in stating a problem. 2006: 46 SESSIO . investing again .engaging with traumatic material and feared situations without being overwhelmed . avoid mind reading and talk only about what you can see.set related homework 2 . be neutral rather than negative. connecting and communicating with others. th pain. don’t jump to conclusions.stocktaking .re-authoring the account of the trauma and its effects .introduction to faulty information ... discuss one problem at a of remedial strategies .’buts’.elicit the client’s account of the trauma . manage shifts in mood and pain 5 the 3 As .. brainstorm trauma and its effects. literacy and remedial strategies. focus on solutions. and involvement of significant other . experiment with a solution..cognitive restructuring. ID saboteurs eg drink/drugs. ‘Yes’. express your feelings.38 30 BOOSTER SESSION S TRANSITIONING TO MONTHLY SESSIONS INTEGRATION OF TRAUMATIC EXPERIENCE AND RELAPSE PREVENTION 1OVERVIEW OF COGNITIVE-CONTEXTUAL PROGRAMME FOR PTSD Scott & Stradling.present the rationale for targeting N 1 the ACCOUNT of the trauma. any changes agreed should be very specific. be brief when defining problems. behavioural change should include give and take and compromise. admit to your role in the problem.elaboration of worst moments. summarize what your partner has said and check with them that you have correctly understood them before making your reply. always begin with something positive. choose a solution. rationale for tackling co-morbid disorders 3 .review 4 As . AVOIDANCE & ALIENATION.frames of mind: ruminating on what I can’t influence v concentrating on what I can influence battle mode v problem solving [define the problem. Tackling ANGER = 4 A. weaning off safety behaviours. be mood records . 4 . review] moaning v investing processes. decatastrophising .

stepping around prejudice against self . but can be prevented from affecting your long-term quality of life. use MOOD to manage mood. use communication guidelines to facilitate support. decide to live in the land of APPROACH rather than running for cover in the land of of thought records and mood management .any issues arising out of last session FORMA .session specific material . distillation of personal protocol to be used in the event of relapse . 12 one month follow-up. decide what to do 18-11 outstanding issues.39 16-7 .emergency protocol: accept that destabilization is likely.mood management = monitor mood. involve significant others as facilitators of the trauma narrative and guides in the land of approach. observe thinking. accept that destabilization will result in more vivid and frequent images of the trauma. objective of homework and troubleshooting difficulties T . fine-tuning and formal reassessment SESSIO .re-assessment .functioning since last session N .integration of all teaching to date into mutually agreed homework assignments . and that old memories will have to be contextualized again by detailing in writing/audio/verbally the story of the trauma and its effects. review use of skills.

ABCDE analysis [Wills.40 1THOUGHT RECORD . 2008: 75] A Antecede nt B Irrational Belief C Conseque nces emotional and behaviour al D Dispute for each IB E Effective rational beliefs F Feelings/ behaviou r arrived at after consideri ng effective rational belief Less anxiety. more resistance to washing hands Blood on money from cash point This is dangerous Anxiety urge to wash hands & change clothes Am I exaggerating the danger here? There is a small possibility of harm but I am exaggerating .

to notice and hold thoughts and visualize thoughts as passengers on a bus . feelings or physiological reactions. You can still make decisions and do not have to control these phenomena. It means to have choices. the here and now. Mindfulness allows us to be aware and to accept the present. to be. and to include these experiences as part of a valued whole life. using the self as observer to put experience in perspective. you will be working on accepting what cannot be changed and committing to things in your life that matter to can still carry on and choose your own direction. sensations. self-as-context. Control is seen as the problem. Make the choice to live intentionally rather than reactively. go to www. but to alter their functions and view them help clients live a personally valued life. Mindfulness will promote well-being. Be aware of misapplied control efforts. be willing to experience. . In the end. Willingness to experience will allow more choices and alternatives. in accordance with personal values. The aim is not to modify Experiential acceptance of emotions. memories and thoughts means tat you will stop avoiding or trying to control them. It is impossible to be happy all the time.41 1 ACCEPTANCE AND COMMITMENT THERAPY ACT helps the client to make room for their difficult memories. Creative hopelessness helps clients to see they are wasting energy trying to eliminate thoughts.contextualpsychology. These reactions are distinct from the self. For more information about ACT. Ultimate goal . feelings and thoughts as they are directly experienced. One will learn to verbalize experiences.

Self-as-context allows you to be aware that you are more than your experiences. 42 . Values provide direction in your life.

contact with present moment.use self as context.Choose .as in CBT.reason-giving . committed action.defusing E . believed.values.43 The aim is to treat FEAR: F . I as content /I as context The following techniques can be used to change I into context: • • • • imagery exercises in which thoughts are allowed to flow as leaves on stream. experience thoughts.individuals view their thinking as the learn to challenge thoughts. choose to give up control T . without being bought.Accept .the thought loses its power and meaning use of imagery to turn thoughts into objects with shapes.this needs distancing from those thoughts .verbal explanations for behaviour Key issues in the approach are: • A . defuse emotions . sizes and colours use metaphor eg the chessboard Let go of the struggle • let go of control.avoidance . find alternatives R .like holding a butterfly in the palm of your hand • • C .try not to think about something will bring the event to mind. adopted or rejected repeating thoughts rapidly . balance distorted perceptions/interpretations with more accurate and insightful conclusions .what is important . problem-solve in healthy ways A .experience emotions/thoughts/feelings/memories/sensations but engage in safe behaviour.Take Action .cognitive fusion . defusing choose to respond differently .evaluation . feelings or memories .

You may focus on your breath or scan your body. but the function they serve. Simply notice negative content as it shows is nonjudgemental awareness of thoughts and feelings . Later you may focus on imagery.44 Techniques used are: Mindfulness Mindfulness is an ancient Buddhist practice . People with PTSD want to have the memories erased. This is not do-able. Do not allow yourself to build your whole life around the trauma as your life will get smaller and you will start to function negatively or suboptimally or become lonely. focus on the present moment. The present moment Observe what is happening right now . 2007: 20]. a transcendent sense of self. defused from the literal meaning . You will realise that there is lot to be aware of that has little to do with the trauma of the past or worries about the future. Mindfulness can be very relaxing and can be practiced anywhere. . this creates clarity and acceptance [Walser & Westrup. It is not the memories that you experience that are the problem. you are 100% acceptable as you are.realize that you do not have to act on them.just listen and see. accept the experience. The past One can spend hours thinking about the past or how things should have been. Try to get back your wonder and beauty about the world. 8-16 sessions will usually be held [duration: 60-90 min].observe the thought as a thought.

Observe the emotion/memory or thought. By telling your trauma story. Suffering is all the stuff we add to it with our minds. The future We can spend hours in our mind worrying about the future. Three dominant means of coping with stressful situations have been identified: • task-oriented .45 It is natural to experience pain or difficult emotions in the face of trauma.solve problem by modifying situation. Fear will come and go. commitment to action . Creating clarity See your experience for what it is. what do you hope to gain? History cannot be undone. Make choices consistent with your values. Practice being present in the moment. but you do not have to spend so many moments in the past. without protest or reaction. Acceptance In this moment we take the experience as it is offered. do not fight with it. There is much more vitality in living a valued life than living a life trying to control your internal experiences.

tension or anger avoidance-oriented .46 • • emotion-oriented . Make a commitment to valued action • • Link to your chosen values and goals Look for workable solutions . 2007: 154].distract attention away from the stressful situation [Follette & Ruzek.

47 Session structure • • • • Open with mindfulness exercise Review homework Main topic and exercises Homework for next session .

thinking. feeling crazy.Being creative 1Things you have struggled with: PTSD. “I am damaged”. If you are feeling confused and unsure. loneliness. anger. feelings of emptiness. Discomfort is something to be felt and accepted. sadness. “Why me?” 48 Positive efforts to make the above go away ❑self-help books ❑positive self-talk ❑self-affirmations ❑therapy .group/individual ❑medications ❑alcoholics anonymous/AA/NA/ALANON ❑religion/spirituality ❑talking with family and friends ❑exercise and diet ❑getting out of bad relationships ❑getting a better job ❑learning more about PTSD ❑understanding myself better ❑mindfulness ❑inpatient programmes ❑acceptance of the trauma ❑taking legal action ❑alternative health approaches ❑vitamins ❑acupuncture ❑meditation ❑ ❑ ❑ Negative efforts to make the above go away ❑alcohol/drugs/misuse of prescribed medication ❑isolation ❑moving from relationship to relationship ❑changing jobs frequently ❑moving frequently ❑running from relationships ❑avoiding people. powerlessness. anxiety. not being forgiven. memories. disappointment. nervousness. thinking. places and things ❑sexual encounters ❑driving fast ❑being angry ❑overeating or not eating enough ❑throwing up ❑cutting or other elf-injury ❑attempting to commit suicide ❑never going anywhere ❑always saying no or yes ❑pushing away people you care about ❑being a workaholic 1To grow a lush and green forest. You have to make space for something new to grow. feeling unliked. you are open to new possibilities. not avoided. lack of confidence. you have to clear out all the old burned and dead trees. pain. low self-esteem. isolation. fear. feeling confused. Staying stuck .

When you dig hole. You are stuck. . find a shovel and start digging.available on CD Homework assignment 2: practice mindfulness meditation . by trying something different. you are responsible for getting out of the hole. You are in a into the hole.Imagine you fall into a hole. You are not responsible for being in the hole. what do you think will be different? Try to find the function of the story. Giving hope to hopelessness Although the situation is hopeless. You are not to blame. memories. Misapplied or rigidly applied control turns out to be the problem rather than the solution. usually you dig deeper and do not get out. Mindfulness exercise 1: Attending to breathing . but it does not work.available on CD Moving forward Creative hopelessness helps one see all that you have tried in order to make experiences. Stop digging. You do not have to solve it immediately. memories and emotions. painful emotions and thoughts better or different. you are not! Imagine that when you fell 49 a hole. If you keep telling the same story for 50 years. It is all about control of your thoughts. However.available on CD Mindfulness exercise 2: Body scan . you were blindfolded.available on CD Homework assignment 1: creative hopelessness .

Remember the hole . Record and monitor any negative experiences and report your reactions . we learn control by direct experience/by modelling.disapproving looks . stated in positive terms. if you drop the rope. they are about observing and contacting experience. spend about 5 minutes per individual reviewing homework and exploring responses to it. not using do not. Write about your personal reflections on being in the struggle Write about the costs of being in the struggle. It is impossible not to think about ice cream! Focus on where you want to go. .explore the nature of paradox . moving furniture around.the harder you pull. scarf or belt . 5-10 minutes.the harder you struggle. only for getting out.control is part of the problem. The exercises are not about being comfortable and relaxed. the harder the other side pull as well.the harder you pull. etc.give your struggle an image . let as much of your body contact it the sand. trauma memories. . The memories are still there. I will give you a whack with a stick .focus on your senses in the present .get over it .CONTROL AS THE PROBLEM SESSION FORMAT 1-2 sessions tug of war image on CD homework 1 &2 on CD control homework ! &2 on CD breathing with light imagery + just listening 50 . push in with both fingers.your machine is your central nervous with mindfulness. they cannot be erased. mindfulness exercise 1: expanded attention to breathing with light imagery. misapplied or rigidly applied control is the problem.if you get carried out to sea by a current.imagine yourself being linked to a machine that can detect anxiety. this can be true for anxiety. there is no more struggle. so you will have more room to move Fighting the wave . the more difficult it is to get out Quicksand . do not fight it as you may get tired and drown.observe dispassionately assignment 2: control as the problem .distraction can work.solution. Chinese finger trap .imagery exercise . it is bound to return. . live your life in the present moment.the room temperature. the more you are pulled down . One may be robbed of personal relationships. We can control many things . this give you some freedom to walk around. golden opportunities.big girls/boys don’t cry .you are not responsible for falling in.explore the paradox of trying not to think about something: do not think about vanilla ice cream! Remember the person in the hole-metaphor.examine how you learned to control: tug of war exercise = cost and benefits of control. but are here to stay. It you suppress a thought or emotion. throwing garbage away. . if you get anxious. your only job is NOT to get anxious.explore sticking points .mindfulness exercise . not the solution. some people learn to hold back tears. is that your experience too? Stop controlling! . the tighter the tube clamps down on your fingers . use the quicksand/Chinese finger trap or the wave metaphor . the memories will be in the background. simple dignity or a life well lived. don’t worry. but they are not fighting against you anymore. or relaxation exercises .assign homework: control as the problem . but at what cost? Usually narrow and inflexible lives. Control may seem to be the solution. Mindfulness exercise 2: just listening. be happy .moving forward Assignment 1: control as the problem .understand the costs of misapplied control.the more you struggle. and will fade with time. most people believe they are no OK as a human being. when you get anxious. use a rope. anger.spread out in it. because it usually prior session.all for the short term letting go of the struggle can bring rest and a sense of liberation .

. Henry Ward Beecher Through acceptance and commitment therapy. one is trying to move into a position of willingness . 2007: 85]. You must take it. without attempting to alter or escape them in some way. The only question is how. an active choice to have and hold whatever feelings there are rather than trying to be rid of any one feeling [Walser & Westrup.51 Willingness God asks no man whether he will accept life. That is not the be willing to have the internal experiences of the moment. It is a stance one takes.

“I am a failure. say them out loud. Now take your ‘mind’ for a walk. the other will be his/her mind. then visualize yourself with your head facing the screen at the normal distance. You will come into contact with your ‘self’.you can choose life despite your experiences. while your mind must be willing to take one step forward .” and cannot recognise it as simply a thought . try to push it away.make choices about your life rather than to accept programming. What do you believe? Anything we experience goes into our programming. and gives you more freedom to go on with your life. you can see the computer with the programmed words on it. just as acceptance does not mean forgiveness. One will be the person. not to engage in unsafe behaviour. our society. people may feel unsafe and may feel threatened. Your job is to walk around the room. then back and forth. bodily sensations] experienced at any one time. As the client pushes. Observe that you will feel more at ease and more aware of other things in the room. one after the other.52 SESSION Introduce willingness = begin with a mindfulness exercise 1 . The therapist now moves their hands in a gentle circle. Give it an image. with the words “I am damaged goods” on the screen. The lesson is that you can override your mind.learn to view the mind from a different perspective. Explore cognitive defusion . so one can modify your emotion. to recognise the continuity of consciousness. you will not realize that this is part of the programming. demonstrating increased freedom of movement.ask for a volunteer . guarding being a control strategy that not only does not manage to prevent pain but serves as an impediment to living fully.Being willing allows for greater freedom. . not necessarily truth. programming. A swamp is something you must get through you know where you want to be . commercials.this will help you distinguish thoughts from literal truth. Press against it slightly. Allow the struggle for a few moments more. does not mean that you want the emotion. and accept your feelings. and help you to see your programming . Let the volunteer tell you something he/she struggles with . will be in a double bind . mindfulness exercise 2: welcome anxiety [5-10 minutes]. rather than engaging in various control or avoidance strategies or trying to change or escape in some way. Accept the facts of what happened. you are no longer focusing on the struggle. Being willing is about letting down one’s guard.the ability to recognise one’s thoughts as internal phenomena. with your head stuck in it. Hands-on exercise . our teachers and friends. Explore sticking points . then give the following instructions: keep your hands against each other. When your head is further removed from the screen.put your left hand against his/her right hand. In the second picture. and to observe [and accept] ever-changing internal experiences. If you are too close to the screen. You are asked to feel difficult mindfulness [5-10 minutes]. just decide which thoughts you will obey and which ones you will ignore. You have a choice! Understand barriers to willingness .at the other side . choose how you will react . If you have a negative thought. Taking your mind for a walk . It is a difficult task to attempt to reconcile the reality of what you experienced . it seems much more acceptable to just allow it to be. but stop trying to push the other away.the burden of freedom means that we are responsible for our lives .imagine yourself sitting in front of a computer. not literal truth.horror.and may get muddy in the process Assign homework: willingness. Imagine the therapist being the ‘fear’/big black blob. We are programmed by our parents. Being willing is about noticing the anxious feeling and letting it be there. you will read the same words. being willing to feel an emotion.moving through swamps . MIND: generate a constant stream of thoughts. Computer metaphor . This illustrates that even though ‘fear’ is still there. our families. One’s ‘observer self’ is then seen as the context within which other phenomena [content] comes and goes. feelings. freedom to make choices despite what one is thinking or feeling.either trying to fix yourself or accept it as true. 1 & 2 1Self-as-context: A distinction is drawn between one’s self and the internal phenomena [thoughts. but realize that the text on the screen is just programming. the therapist pushes harder. fear and shame can be immensely aversive. We can help ourselves by recognising our programming for what it is. Pick a partner for this exercise. Persons may not talk to their minds. one is not trying to block it.

drinking? Then what? Do you feel shame or hate yourself? There are now a big pile of tissues in the basket. there is a cost to spending one’s effort and energy on attempts to make unwanted thoughts and feelings go away. Remember there is a self. You can be the chess pieces. Do the same exercise.awareness of body.acknowledge the importance of history.being aware of emotions/thoughts and feelings .it experiences the pieces .‘life sucks’ . does not always know best .open with mindfulness: mindfulness exercise 1: recognizing mind quality mindfulness.tissues are thoughts/emotions/senses. this board extends endlessly in all directions. ask a peer to write a label on a post-it sticky paper and stick it to the volunteer’s body. This will enable you to view it from a different. grab a box of tissues and a presentfocused work . the player or the chessboard. you have many identities .53 SESSION exercises and homework on CD . thoughts are transient. you are not defined by labels. The observer is larger than the experience or the traumatic memory. Missing the point . Holding too tightly to an identity .assign homework: 1 .PTSD .try the following labeling exercise to define self-as-context in a group or individual setting . and yet not be experienced war/an accident / a disaster . a continuous you. and remains.yet somehow remains intact .what comes up if your thought is ‘life sucks’ . Do the exercise: selfas-context: letting go of identity.private events/thoughts/feelings/physical sensations are experienced by the self.[take a few tissues. therefore one does not have to be rid of experiences to be whole. how do you feel? [anxious. not content . emotions and sensations . 2 . son/daughter. All pieces are linked to the first piece.when something bad happens to you . remember there is a continuous you . If you are the board.use an actual chessboard .point out the costs of clinging to a specific identity . You will realize that context is not the same as content.the self is context.emotions and thoughts come and go . and holding that thought or feeling to be true.ask for a volunteer to stand next to you. Some people will initially have fun when covered with labels. events come and go.but it does not care which side is going to win! It can hold all the pieces. People usually want to get rid of the bad pieces . put it in front of the client = you are the wastebasket . What do you see? Realize that there is another person behind all the labels. toss them in the wastebasket] . lover/friend . intact . We will always have more experiences. who is having the experience. Positive thoughts and feelings can be just as easily recalled. Remember the tissues are not the basket. thoughts.there is often confusion between consciousness and thoughts. 1999] . We use the chess pieces to depict the struggle between good and bad thoughts/feelings and that the game cannot be won. efforts to control are ineffective and will add to the problem.some clients will identify with being a victim . Cargo space . Thoughts come and go. Think of other experiences that were not traumatic. Try to cover it up or hide it away. The board is the context that holds all the pieces of experience.begin to place the various pieces on the board. As we go through life we are continuously picking up new experiences [demonstrated by adding new pieces to the board]. Trauma-related thoughts just happened to grab your attention. Thoughts and feelings are content within the self.discuss the concept of an intact self . but as soon as you begin to identify with the labels. They cannot just be thrown off the board . Remind clients that history is additive. you may become quite prior session . When covered with positive thoughts and feelings. but with a different colour of labels . consciousness is larger than experiences. the self is intact and can experience difficult thoughts and .you are not the accident/disaster or war.self-as-context: letting go of identity . You will be able to think about the experience.each moment contains something different to be experienced. explaining that they represent various experiences. less frightening perspective. just something in it. the traumas .write on label and attach . easily evoked. crumple them up. You are more than the labels.mother/father.What do I feel good about? Divide the group into pairs .Look at each other.. The self is.the self is not broken . Tell me something you struggle with . Remind yourself of the difference between having a thought. you will feel different in a matter of minutes.they are not so easy to get rid of. losing control] Then what? Are you distracting yourself with . The board is strong and solid.they are not stable and ever present . and remember using all your senses. experience them. they are just words. you are free to go wherever you want.the painful memories.put on label .and loses the distinction between having been a victim and currently being a victim . The board is in contact with the pieces .same with ‘something is wrong/fear/sadness/I can’t get over this/depression/hate myself/I do not want to live/I hate myself even more/etc until the volunteer is covered in sticky cards. The self can be just an observer. ‘I will never change/I will always be alone’ v I have always survived/I have hope/I have never given up/I am brave/strong. Label parade .therapist is not one can be an observer.exploring self-as-context + tracking or survivors state that they have no idea who they are. History is additive. sweating. but who is more than or larger than those thoughts and feelings.the board is free to move despite the presence of even very difficult pieces. Ask clients to group good/bad experiences/chess pieces together. or lacks a whole self Playing chess . 2: finding-thecentre mindfulness .explore sticking points .the-box-with-stuff-in-it [Hayes. thoughts and feelings from your life.

Euripides Up to now. Live according to what is most important in your heart of hearts. You can live according to your own values . feelings and memories without having to use control strategies. clients have been learning to make room for their histories.54 Valued living The wisest men follow their own direction. .that will give life inherent value and vitality. how to simply experience thoughts. We can make decisions based on how we are feeling.

letting go of ID .the what-do-you-stand-for exercise [Hayes et al. it is not about reaching a destination.consider what you care about .help clients ID their values . physical is very easy to generate reasons Providing direction and meaning making . dream .. but change the ending..values are like points on a compass . she was about being loving. one will bring choices aligned with values to life. anger or outrage. This implies commitment to action.explore valued living . how you would like to be.” This demonstrate the difference between values and roles.imagine your own funeral .live with intention. employment. We all hold internal experiences and move in valued directions.they point you in a direction. but what will guide our choices as we move through life Compass metaphor .you are looking back over the past 5 years . trust in others. On the second is worth would you like to be remembered? What would your friends ideally say about you? How would you ideally be remembered? Here lies Mary.self-as-context. Watch out for anxiety . 2 place of peace . there is only do. acknowledge that life is not fair..55 SESSIO N 2-3 session s exercis es and homew ork on CD . not traumatic memories. colour. personal safety and the safety of others .draw two headstones on a whiteboard . do you want to regret your life. ID lost values. write the same. and spirituality. . love and protection .choose between Coca-Cola and Appletizer .there are no right values. Willingness is a choice Over the next couple of sessions.choose simply because you can . as is .develop values and goals .what would your life look like if you made valued choices? .personal choice.”.assign homework: ID and clarify values.. the process is the point . . What did you appreciate about them? This will help you articulate your values and future possibilities. or do not. . the choices we make will define one’s life. or do you want to make choices in the direction that gets you closer to where you want to be. one can still value fairness.personal safety. not uncomfortable sensations or thoughts 1Committed action There is no try. Imagine 5 years from now . about behaviour. ingredients .moving forward . “Mary was about . .finding meaning after PTSD .why do you want your children to be happy? So they can be happy with you as provider of food. taste. some may experience pain over the unfairness of an is about action..on the first one write: “Mary was about .nothing sands in the way of a valued life: not feelings.use the worksheet to ID values and goals regarding various life domains such as family prior session .reasons are not causes of behaviour . pride.To find out what you care about.aim high! Think about someone you admire.. core values can be the right to be treated with respect and to be valued. Headstone exercise .being a loving mother.explore sticking points .examine values and trauma .making sure not to feel PTSD symptoms.survivors may have some of their values violated or overturned by choose behaviour based on values Choice making .open with mindfulness: 1 compassion mindfulness. 1999] . . who had a positive impact on your life. some experience losses .

you can still keep driving where you want to go. or a piece of paper! This nicely demonstrates how action can be taken. . making a commitment to action/a value . unwillingness can lead to loss of vitality and engagement.applies to suffering and anger .being heard by a focused listener may have a freeing impact . giving the cold shoulder. sometimes you have to look at them. people who want to be right usually find that others will keep their distance and do not want to talk.ID remaining barriers: complete unfinished business.obstacles to willingness can be reason giving and emotions. including shutting others out. even for a moment. you do not have to jump off a building. say to this self . do not wait for a return or how others may respond.revisit willingness . you can get off and stop anytime. not the target. so that the only way for the client to get off the hook is to let the nonforgiven person off the hook first .it is not possible to get rid of the monsters. notice that you are still here.“I let go of you... frightening others. because it works to do with mindfulness: mindfulness exercise 1: We are all in this together [10-15 minutes]. Forgiveness means “to give what went before the harm was done” . Do not say that you will like choosing a road up a mountain.nonforgiveness may interfere with values.what game do you choose to play . so is values. you can take off the glasses. hiding out or behaving inappropriately through violence or yelling.imagine a bus with passengers monsters and good guys .in this metaphor. the following topics may be difficult: forgiveness.moving forward SUMMARY OF STAIR/MPE SESSIONS S T A I R = Skills training in affect and interpersonal regulation MPE = Modified prolonged exposure [Follette & Ruzec.tell the ACT story .describe how that self dress and look/think/feel. Clinging to the conceptualized self . isolation or not allowing yourself to live the life you would like to live A worm stuck in a hook . thoughts and feelings are transient. Each of these tends to be strongly linked to efforts to control internal experience .many trauma survivors cling to an idea of who they are.explore commitments . the client is on the hook first and the nonforgiven person is second. right and wrong clients can get caught up in failed relationships characterized by issues of who was right and who was wrong. behind the yellow line. Imagine sitting in a chair.not wanting to feel sad or hurt .choose to behave in a forgiving way..each pair takes turns to describe at least four selves eg professional/ working self/ victim/survivor/ struggling self/ current self/ best self .so one may feel a sense of relief. Think of the person you are in the process of forgiving. remember that skiing is a process. concern about right and wrong and clinging to the conceptualized self. You may practice with a volunteer.anger usually harms the person who is angry. maybe a chair. process [having fun] is more important than the outcome [getting to the bottom of the hill]. visualize this self .assign homework .review prior session . would you be willing to choose what it is that you want your life to stand for? .under the anger is usually hurt feelings. you may say things you have never before expressed .regain values: we continue to define values and dismantle barriers.1 & 2: committed action .” after you have focused on letting go each of these selves. 2007: 337] .Pair up in twos . just do it! .56 SESSIO N 3-4 sessions . there is also a self that is experiencing the mind . gradually one will be more active in regaining values. Close your eyes gently. 2 Kiss the earth with your feet . lightness or peace . Punishment can take many forms. with an empty chair across from you. imagine what it is you need to forgive. and get back when you one evaluates and responds according to the colour of the glasses. non-forgiveness and self-blame can lead to years of heavy drinking. or may have punished others for deeds done.sitting lightly on your hand like a butterfly imagine this sense of self dissolving. The following exercise will help people to get a little distance from their conceptualized self .explore sticking points . choose to be willing.ask the willingness question . linked to roles of victim/ survivor/ child/adult/employee. the mind is like a pair of rose-coloured glasses .

generate alternative schemas 7 Assertiveness and control schemas .IP schemas as self-fulfilling prophecies . MPE 9 Introduction to imaginal exposure . generate alternative schemas 8 Flexibility in schema application .postexposure implementation of stabilization exercise.practice new coping skills 3 Emotion regulation 4 Distress tolerance: . do role plays using flexibility skills.emotion regulation. ID relevant IP situations and act out with role plays.trauma related schemas and ‘here-and-now’ interpersonal goals .psychoeducation .ID schemas in a current problematic situation 6 Alternative IP schemas . ID labeling of feelings and schemas.develop narrative. contrast trauma schemas with current developing schemas . PTSD symptoms .psychoeducation about connection between feelings/thoughts/behaviours .Practice of focused breathing 2 ID and labeling of feelings .psychoeducation .ID strengths/weaknesses in emotion regulation skill . do role plays using assertiveness skills.Psychoeducation and discussion of alternative schemas and behavioural responses.introduction and practice of self-monitoring of feelings.Treatment overview and goals . intensity and coping/reaction .57 SESSI ON FOCUS AND CONTENT SESSIO Introduction to treatment: N 1 . generate alternative schemas. IP functioning. create trauma memory hierarchy 10 Imaginal exposure to first memory .accepting feelings/distress .role playing.assessment of pros and cons of tolerating distress . triggers.ID and practice of pleasurable activities 5 Distinguishing between past trauma schemas and current goals: .psychoeducation.

58 11-15 Continued work on imaginal exposure
- working through memory hierarchy with probes, clarifications, and greater evocative details; continue to analyze narrative ito feelings - ID progress, risk for relapse, use relapse prevention strategies

16 Wrapping up:

59 Kinchin [2007: 49-58] compares six models of debriefing:
MITCHELL 7 phases DYREGOV Norway PARKINSON 3 stages KINCHIN Emotional Decompres sion
Introduction: Diving in Debriefers introduce themselves Explain aim and purpose Explain rules and get agreement from group Stage 1: Deep water



1. Introduction & rules

introduction & rules


Introduction and rules

Introduction and rules

2. Facts -

Expectations & facts

Stage 1: Facts

What happened? What did you do? How did others treat you? How did the incident end? 3.Thoughts What did you think? What did you do? How did you treat others? How did the incident end?

What happened? What did you expect? How did others treat you? How did the incident end? Thoughts & sensory impressions What did you think in the beginning and later? What did you do and why? What sights, sounds, smells, tastes, touch sensations did you experience?

What was happening before, during and after the incident?

Initiation into disaster

What was happening before, during, after the event?

What happened before incident Level of training Positive/nega tive What learned?

ID most troubling events

focus on past reactions to stressors and coping styles

Stage 2: Feelings Sensory impressions sights, sounds, smells, touch, taste Stage 2: Emotions What feelings and emotions were generated?

Stage 2: Middle water What physical reactions were experienced?

negative/posi tive aspects and feelings

Feelings and reactions to difficult events


Feelings How did you feel in the beginning, and later? What was the worst thing about it? How do you feel now?

Emotional reactions

Stage 2: Reactions

How did you feel at the beginning and later? What was the worst thing for you? How do you feel now?

What physical reactions? What feelings and reactions are present now? Any positive reactions? Lessons learned?
Stage 3:Future

What feelings and reactions are present now? Any positive reactions? Lessons learned? Sensory impressions? Feelings and emotions generated?



What physical and emotional reactions did you experience at the time & later?

Normality of reactions Explain possible reactions

Normalisati on

Stage 3: Breaking the surface


Relationshi ps with others

Coping strategies past and present

Normality of reactions Prepare for possible future reactions

Future planning & coping

Stage 3

What help do you need? What support do you need? What have you learned?

Gives info about possible reactions Support personal, org, group, external Aftermath: court cases, inquests, inquiries, funerals

Info about future reactions Coping strategies Snakes and ladders model of recovery Support: personal, group, org, external Aftermath: court cases, inquests, inquiries, funerals

Feelings of victims

Re-entry What support is needed? What support is available? Any questions Info and leaflets Remain available after debriefing Follow-up essential.61 7. referral as necessary Time: min 2 hours Disengagemen t Endings Any questions? Issue info/leaflet s Follow-up and referral Be available after session Final statements Referrals Refreshme nts Endings: Treading water Disengagemen t Final statements Referrals Further info Refreshme nts Focus on leaving the disaster and returning home Time: 1 ½ hours Time: min 3 hours .

trauma encoded h . fla .worried about what did happen [Scott & Stradling.troubled more by w happened . spectator view at same time to AM = brain’s emotional alarm system . long fight/flight response term memories .react to stimuli.part of cortex .DORSOLATERAL FRONTAL CORTEX .within seconds .ANTERIOR CINGULATE + .corrective info to AMYGDALA .cope by dissociation .distance. perception-based info based on senses .recent conscious memories.emotional respons .freezes trauma.trauma encoded here .62 DUAL ATTENTION THEORY 1 Brewin and Turnbull states that there are two different memory systems: VAM verbal accessible memory.react before think . slow response . can communicate info through language and speech .current sense of self .amygdala Incoming sensory goes to THALAMUS then to HIPPOCAMPUS HYPOTHALAMUS = controls . do .compare previous experiences .locate event in time and space . 2006: 29-34] CONTROLLED DEMAND: .non-conscious res .executive control .hippocampus/cortex SAM sensory/situationally accessible memory.

You may get angry because the alarm goes off so easily. In PTSD the alarm can be triggered by very trivial things. green [ta DEALING WITH PAIN 1 Pain is often a consequence of trauma and often reminds one of the incident. Gradually you have to go places you have been avoiding. amber. Talking and writing about the incident will help you integrate information from different parts of the brain. The normal setting of the alarm is on the left. . Gradually you will be able to take charge of the memory. Initially it will ta the bubble and reconnect yourself for being in the bu responsible for the problem solution. and they cannot have not been through the behaviour means graduall feeling of flatness and disc will feel like a robot going fake it till you make it .anterio dorsolateral frontal cortex hippocampus and amygda the fear will still be there. so do not wait for them before doing something. S emotion while you realize that it is part of a backgrou You can also visualize the robot . but you can only stop it with practice by collecting info daily that you are not in a real war zone. a few seconds each day. This system is aware of how serious the alarm/amygdala is and can send a corrective message. You connect with others. Memories are on more you avoid them or pu they spring back. so why try”.63 Counselling will therefore focus on three parts [Scott & command system . Learn to with distressing emotions. Pain is linked to tissue damage. :I need to wait for a pain free day before doing anything/I can’t. Remember that pain free days may be the ideal. it just feels like [stop to think if on facts]. it moves over to the right . b over time. The hippocampus updates the trauma story as it gains more access to initially forgotten info. When something extreme happens. but also thinking and emotional states. becau different. 2006: 49-50]: The brain’s alarm: the amygdala There is an alarm deep inside the brain called the amygdala. The bubble and em People who have had very become very concerned a emotional flatness. as a re producing opiates during t may feel like lemonade wi return gradually and often engage in increasing dose also feel in a bubble. Negative beliefs may also block people from being who they were before the trauma. The story of the trauma The drama of the trauma is written by the brain’s hippocampus and possibly the pre-frontal cortex.war zone. the dotted line .

Monitoring pain Pain should be monitored so that you can learn what factors increase/decrease pain and adjust coping strategies accordingly. Dare yourself to try various activities. try to practice objective thinking [O] and decide on a pain management strategy [D] with detached mindfulness. 2006: 129] proposes that the brain has a neural network that integrates information from multiple sources to produce the sensation of pain . do not think too much about it as it may render you helpless. . how does your headache feel now? Most often you will find that the sensation of pain is heightened by a worsening mood. Remember. what happens to the headache? If you just had an argument.inputs include sensory information and inputs from the body’s stress regulation systems. See if you can disconfirm negative predictions.64 Pain Management programmes are usually presented at major hospitals and involves attendance of 8 half-days a week with a follow-up at 6 weeks and 6 months. the experience of pain is more than just tissue damage. Lower back pain may be treated by increasing activity levels. Remember that others cannot read your mind. Try not to magnify pain. Cognitive restructuring and attention control A flare up of pain can result in a downturn in mood [M]. observe [O] your thinking when the pain is really bad. Try to get involved in tasks that capture your attention. Thinking and emotion will also play a role: If you have a bit of a headache and you get the news that you have won the lottery. do not expect to be pain free every day.accept some pain. as simple as going shopping. CBT pain management has 7 components: • • • • • • • education and socialisation into therapy relaxation exercise and fitness behavioural contingency management attention management cognitive restructuring social and family management Education and socialisation The neuromatrix theory of pain [Melzac in Scott & Stradling. Stop ‘all or nothing thinking’ . Keep a log/diary of your pain. noting the pain intensity. thoughts.attempting to do tasks at the speed and for the duration as you did before the injury. mood. Accept the pain with detached mindfulness. as that may result in you being immobile and demoralized for days. at minimum: morning/afternoon/evening. activities. Do not alternate periods of inactivity with ‘blitzing’ . tell them how you are feeling. you are in a bad mood.

Denial. they are never likely to return to how they were before the event. Communicating about pain Even when people care. Horowitz gives it as Event. Try to invest in various activities and pastimes. jaw. days/minutes”. which leaves some scar tissue. “There is likely to be pain today. Prevent preoccupation with pain Accept the pain as part of your life if you cannot be pain free every day as this state is highly unlikely. Testing and Acceptance. “It does not stay this bad for more than .. especially neck. Immobilization. Refuse to see the experience of pain as a sign of weakness. hands and shoulders . just realistic. Prevent family from having unrealistic expectations by telling them the truth about your pain. Guilt.. PHASES OF PTSD RECOVERY Williams gives the phases as: Stressor.. Denial. they cannot read your mind.65 Prepare before you try to switch your focus of attention from the pain to something external . Scan your body quickly. Anger at the injustice of pain is normal. Intrusion. This may not reduce pain significantly. Outcry. otherwise there will be no return. even with full recovery. So. Working through and Completion. but it makes you more aware of your senses.a computer game or imagine the pain filling various coloured balloons floating away with your pain. Try to separate acceptance of pain from anger at the perpetrator. victims of trauma incorporate the event into their life experience with psychological scarring. You can still make a difference and influence the pain. feet. You may also use the ‘signal breath technique’ of Hanson and Gerber.release areas of excessive muscle tension as the breath is being exhaled. At the moment the breath is released. but sometimes it is not as bad as others and there are better and worse ways of playing it”. Relatives and friends can be very valuable in keeping you active at the appropriate pace and in making sure you continue to invest in life. Use the following coping self-statement. You have to tell them how much pain you are experiencing. Anxiety/Anger. You are not ‘moaning’. tell yourself to ‘relax/let go of the pain’.Keep It Simple Stupid! Own up to what you can/cannot usually do and simply re-iterate this at appropriate times. Like a physical wound. Depression. even if it is not possible to completely eliminate it. The snakes and ladders model of recovery . Use KISS . Take a deep breath that is held for a few moments and then released slowly.

Recovery is not smooth or predictable.time can be a great healer Advice from Aileen Quinton: • • • • • • • • claim the right to experience and express your own feelings allow yourself to be sad or to cry take every opportunity to talk if this is helpful the situation is abnormal.good medication.reaching the top 9 nine squares is good enough for recovery . at your own pace. Examples of snakes and ladders which might affect a person’s recovery: SNAKES . recovery begins. take ‘breathing spaces’ after achieving goals or accept temporary regression of progress if necessary do not push yourself too fast just to please others be empowered to make your own decisions . 2007: 95].unrealistic goals LADDERS . and to re-experience previous anguish and turmoil [Kinchin. which may take the survivor back towards the start of the game.relaxation techniques . especially the first.alcohol.realistic goals .individual or group support . The traumatic event takes place on square 1.66 PTSD sufferers find themselves playing a game of emotional snakes and ladders.emphatic counsellor/therapist .triggers: sounds/smells/specific situation .anniversaries. to feel trauma is normal make contact with others in similar situations be encouraged to progress in an individual way. some never finish the game and never finish exactly on square 100. A series of ladders helps the person on the way to recovery. Some people recover in less than four weeks.adverse publicity may increase guilt .trauma bond/you are not alone/people with similar experiences .panic attacks . They may give up.therapy/counselling or any kind of helpful support .depression . The game board represents the road to recovery.non-acceptance of PTSD . can be a milestone or a hurdle . but between ladders are snakes. antidepressants . divided into 100 squares. medication as an initial crutch may become a dependency . drugs.

During . after Emotional reactions. To share your recollections with others. just how did you feel? How do you feel now? Look out for people who may appear to have difficulties Individual vulnerability in situations. What did you think would happen? How prepared were you? What could have happened? ➁ Aim To clarify the event and make sense of what you recall. but it is very normal to react ... later that night. After. during. except attendance register Don’t share this with others.. confidentiality clauses No notes will be taken.. disturbances. After . To feel more comfortable with what you may have witnessed ➃ Feelings First thoughts: sensory impressions before. feelings afterwards. right now! ➅ Future Look at support networks Sharing emotions and feelings Important that others understand the impact on YOU Warning of other events ahead: COURT FUNERALS Teaching on PTSD ➄ Normalising These feelings are actually normal elaborate Enforce the ‘normal’ in all of this Coping mechanisms Not everyone will react in the same way Intrusive images will diminish over time Don’t actually need to react to be normal. at home. this is normal and will soon pass ➂ facts Expectations immediately prior to the event Before . except partners May feel a little worse immediately after the debriefing. outsiders Introduce self. 2007: 127-130]: ➀ Introduction No telephones..67 EMOTIONAL DECOMPRESSION PROMPT CARDS 1 The following seven cards may be used by debriefers [Kinchin..

Australia. M P. L. NSW. 2004. Effective early interventions for treating acute stress disorder. 1997. Springhouse Corp: Pennsylvania. Mental health and psychiatric nursing. TalominBooks: Mascot. Giarratano. Clinical skills for managing acute psychological trauma. .68 ➆ Disengagement Allow time for questions Make sure there are sufficient drinks and biscuits! Give information on self-referral and PTSD and other useful information Thank people for attending Make sure YOU stay behind and are able to meet individual needs 1 Sources for further reading: Benner.

69 .