TRAUMA COMPETENCY SKILLS:

Review of Linda Curran DVDs

Through this continuing education series, a practitioner can gain a good understanding of the trauma response, the use of EMDR techniques for stabilization of clients who have experienced trauma, and the use of EMDR techniques to reprocess the trauma after stabilization has occurred. Linda Curran provides a fascinating examination of the biological responses to trauma in her step-by-step guide on how to work with trauma clients. Special highlights of the Trauma Competency: Stabilization video are guest interview clips from trauma specialists Van der Kolk, Levine, and Porges. Curran also includes in-session demonstrations in all three videos.

In the initial stabilization video, Curran points out that "trauma is a natural human reaction" to a stressful event. The basic fight, flight, or freeze response occurs initially, but trauma does not occur until a person becomes overwhelmed and cannot react. We have all felt the relief when we managed to avoid being involved in an accident, but we do not become traumatized because we have processed the reaction. Alternatively, if we are involved in an incident that is so traumatic that we cannot deal with it (due to size, age, or many other reasons) our bodies will continue to exhibit the same response symptoms over time. As therapists, we consider this unprocessed trauma. In this model, the response to the precipitating event is normalized through psychoeducation. All behavior is adaptive. Clients learn to recognize and then to manage their symptoms. Curran asserts how important it is to stabilize the client before beginning to process trauma. Stabilization begins with creating an environment of trust and safety. As with other modalities, the therapeutic relationship is a cornerstone of treatment. Without trust, the client will not progress.

After establishing safety, the client needs to enter a state that is relatively free from crisis; according to Curran, this is any significant emotional, behavioral, or relational trauma. In response to trauma, a client may dissociate. Techniques are demonstrated that help a client get out of the dissociative state, into the present, and into their body. Biological cues are recognized to help clients develop insight into their own feelings. The therapist may direct the client to notice the floor under their feet, or the arms of the chair under their hands. Observation skills are crucial, so that the therapist can track with the client and bring them back to the present if they drift away. These techniques are helpful as well as the review of complex and simple PTSD. Accurate clinical assessment and diagnosis is crucial in determining the treatment plan, which includes projected length of treatment and speed with which a feeling of safety can be evoked in session. Questions in the book, Trauma Competency: A Clinician's Guide may serve as an assessment guide.

Curran explains the similarity between complex PTSD and Borderline personality disorder (BPD). This leads to the conclusion that many clients may be misdiagnosed with BPD, however, she asserts after this explanation that the difference does not matter, as the treatment is the same. She explains that it is important to share a diagnosis with clients from a psychoeducational perspective to reduce misperceptions (e.g., I'm crazy!). Treatment begins with sharing the diagnosis, helping clients recognize their symptoms, teaching that their symptoms may be managed and reduced, and they can develop their strengths and resiliency. Curran presents both Cognitive Behavior Therapy and Dialectical Behavior Therapy as models for symptom management.

Based upon previous work on attachment (John Bowlby) and development of relationship in a traumatic environment (Judith Herman), Curran explains that the therapist must model, explain, and engage the client in relationship. Mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness are used in this approach. In teaching symptom management, the therapist must collaborate with the client to develop a crisis plan, which includes how accessible the therapist will be. The plan should address such questions as (a) Who am I calling first, (b) What will I do next, (c) When can I talk to you. The crisis plan is reviewed in session. When working through symptom recognition, the client identifies strengths and recognizes the costs of behaviors that have served them to the present. Thus, the client begins to build a toolbox of coping behaviors.

Sample sessions demonstrate acceptance of the client's actions, stabilization, recognition of the costs of the behaviors, techniques for emotional regulation, and finally use of tapping or electronic stimulus to help ground the client in the present as the client processes trauma. The emotional freedom technique utilizes tapping and may be explored at www.emofree.com . A mantra accompanies the tapping such as, "Even though I feel scared, it's not happening now." In the demonstration, the client is led through a series of tapping acupressure points and repeating the mantra.

For those interested in learning more regarding polyvagal theory, a discussion is presented based on Stephen Porges work. This fascinating approach posits a triune autonomic nervous system (as opposed to a dual system - Sympathetic and Parasympathetic). When an individual goes into a primitive parasympathetic response to a threat, the body begins to conserve energy. Oxygen level goes down, metabolism and heart rate slows, breathing becomes shallow, (considered the freeze response) and bonding ability is lost. During this reaction, the fight or flight response becomes thwarted and must be completed in treatment. During the dissociative dorsal vagal response, the face will appear vacant and inexpressive. The client needs more oxygen. When he can begin breathing more deeply, he is getting out of the dorsal response into the sympathetic response, which needs to happen in a slow, smooth transition. As this occurs, a lot of energy will be released (which may be fear, anger, etc.) which may result in trembling or shaking as the client discharges the energy. The prefrontal cortex must be engaged to deal with the threat. The front part of the response is called the ventral vagal response or the social engagement nervous system. This system controls the lifting of eyelids, facial muscles, larynx, pharynx, muscles of the mouth, and the middle ear. When the client begins processing in this system, more energy is exhibited in the face. Grounding is demonstrated to "bring the client back" to the present.

The next phase of treatment is resource development. Telling of the story is postponed until the client can be present. Bilateral stimulation may be used involving criss-crossing the arms and tapping the upper arms or thighs or snapping alternate fingers. These stabilization techniques assist the client to stay in the body and regulate affect. The stabilization process can take anywhere from two months to a year. Resources must be internalized in order for the client to feel more effective. The client is encouraged to identify a time that was an exception to the feeling of fear. This time may include images of protector figures, nurturing figures, and a safe place. The goal is to tie the image, thought, emotion, and feeling together. "Neurons that fire together wire together," asserts Porges. In development of resources, imagery is used to develop and install a container. In the demonstration, the client imagined a well in which she could put things. She was given permission to take them out any time she wished, and was instructed to visualize a heavy lid she could pull over the top. The client was utilizing bi-lateral simulation during the visualization to reinforce the imagery. She was instructed to breathe into the feeling of dropping something into the well, and walking away. This was reinforced with the stimulation for six cycles to reinforce the relaxation. The client was instructed to practice the visualization outside of session, but not to tap due to the possibility of free association of other memories that would be reinforced in the process. The same sort of process was used to introduce a protector image. Once these resources are installed, the treatment proceeds to Eye Movement Desensitization and Reprocessing (EMDR) of the trauma.

In the use of EMDR for reprocessing, the therapist explains that EMDR is a misnomer, that rather, the other side of the brain is being accessed through bilateral stimulation to help process the trauma memory. The client is assured that there is no "doing it right". Additionally, any information that begins processing in session continues to process between sessions. The client is instructed to keep a journal and bring it to the next session. This process does not remove the memory, but the emotional charge connected to it is gone. The individual will have a coherent narrative after treatment, but not the feelings associated with the bad memories. Initially, the client utilizes guided visualization to enter their safe place. They then signal the therapist when they have reached that place. This place is a refuge when the client wants to bring their feelings down. Then bilateral stimulation is used like the Theratapper, an electrical stimulator that the client can hold. As in other behavioral approaches, this imagery includes all of the senses to reinforce the visualization. The stimulation is used again and the client is instructed to breathe into that feeling. Then the stimulation ceases. This sporadic use of stimulation continues to keep the client grounded in the present while experiencing the imagery and subsequently reinforcing the more positive state to override the negative one.

Next, the client is asked to recall the worst of the traumatic incident. She is asked to connect the thought, feelings, body sensations more and more. The more she feels it, the more the neural net is activated. The therapist keeps reminding the client that the situation is not happening now; she is safe. The client talks throughout the process as the therapist asks her, "What are you noticing?" In this technique, the therapist encourages the client to keep pushing forward. When the client has brought up the worst of the incident, the therapist asks her to scale the response. On a Subjective Units of Distress (SUDS) scale of 0 - 10, with 0 being no response, and 10 being the worst possible response, the client reports a number. She is prompted to think of the image that goes with the worst of it and then to think of the thought that occurs when that image comes up. The therapist asks, "When you think of the incident, what would you like to think of yourself?" The prompt is made that this thought too can change over time, that the most important part is the thought of the worst of it. The client is then prompted to focus on what feelings come up, and asked to identify the strongest of those. The therapist asks the client where in the body she notices the feelings and what it feels like. When she has identified it all, the therapist reviews all the parts and activates the stimulation when the client agrees she has it all. The client is then asked to talk through whatever happens. The therapist continues to ask the client what is going on and helps the client process until it ends organically. This sequence is repeated: bring up the worst of it (describe), feelings (describe), thoughts (describe), feelings in body (describe), when you have it all give me a signal, begin bilateral stimulation, let the scene run, just notice it, stay in the tension.

Finally, Curran explains flashbacks. She proposes that memories degrade over time, but traumatic memories do not degrade until they are processed. The EMDR procedure helps get the memory into a narrative or semantic memory. She explains to the client that all of that sensory information is of no use currently. She provides several techniques that the client can use when flashbacks occur to help them get out of the parasympathetic response. The hand can be placed on front of head (the frontal lobe is activated in the sympathetic system) to bring blood back to frontal lobe to get executive function back. Ice water on the face brings the individual back real quick. Another technique for people that dissociate is counting things in the room or asking them what they hear. Encourage them to stay present, eyes open. You can have them hold ice saying, "even though my body feels scared, it's not happening".

Curran demonstrates how to handle a flashback in session, grounding the client in here and now. She asks questions like, "What's happening? What are you noticing?" She instructs, "Ok, you can stay like that, but I want you to look around. Do you hear my voice? Who am I? Look around, do you know where you are? Say even though I feel scared, it is not happening now. Say what you see...breathe...what else do you see? Pay attention to that feeling, put your hand on your forehead, and breathe...Name three things that you see, two things that you hear. Do you feel the chair under you? What does floor feel like under your foot?"

After completion of each of the videos in this series, the DVD offers a continuing education post test/evaluation form. The participant can print out the forms, answer the questions, and mail in to PESI for a nominal fee and receive the CEUs. These videos are very informative and offer an excellent introduction to the trauma competency approach.

Debra Leggett, Ph.D. is Associate Professor and Associate Department Chair of Psychology and Behavioral Sciences at Argosy University/Sarasota.