Cancer Wellness Center Trauma Training

DR. ASHLEY ANNE, LPC, RYT-200MAY 20, 2015

REVISED/UPDATED SEPTEMBER 2019

Overview§ Healthy Humans: An Introduction to the Nervous System

§ Regulation Theory: How the Body Manages Threat

§ Trauma and Triggering Moments

§ Cancer Diagnoses, Traumas, and Triggers

§ Nine Steps to the Other Side of Triggered™

§ When Cancer is the “First” Trauma

§ Short Term Therapy: Special Considerations

Healthy HumansAN INTRODUCTION TO THE AUTONOMIC NERVOUS SYSTEM

The Triangle of Well-BeingMind

◦ Embodied and relational process◦ Regulates the flow of energy and information

Brain◦ The extended nervous system: brain, spinal cord, central/autonomic/peripheral nervous systems (includes body proper)◦ Embodied mechanism of flow of energy and information

Relationships◦ Interpersonal connection between people◦ Shares the flow of energy and information

We can think about the triangle of well-being as a metaphor for how mind, brain, and relationships transfer energy (the capacity to do something) and information (patterns of energy that serve as symbols for meaning).

“The basic proposal of interpersonal neurobiology is that integration is the fundamental mechanism of health and well-being” (Siegel, 2012).

The Triune BrainBrain stem: Reptilian Brain (BODY)

§ Manages instinctual mechanisms of the nervous system§ Regulates automatic bodily experiences and shifts

Limbic region: Mammalian Brain (MEANING)§ Responsible for assigning meaning to experiences, memory§ Determines whether something is “good” or “bad”

Prefrontal Cortex: Human Brain (STORY)§ Responsible for logical thinking, reasoning, abstract thought§ Assigns a story to experience

When all of parts of the brain are connected and communicating with one another, this is called integration.

Neural integration is the mechanism for well-being (Siegel, 2012).

Emotions: Neural IntegrationEmotions originate in the body as sensations designed to create actions (i.e. an evolutionary drive).

Emotions occur when:◦ a physiological sensation (brain stem) ◦ is assigned a meaning (limbic system) ◦ and this sensation is combined with a story (left and right

prefrontal cortex).

When these are combined, the energy and information travels to the dorsolateral prefrontal cortex.

This is the area of the brain that allows the individual to become aware of the emotion, which allows the person to choose to take action based on the evolutionary drive.

Brain Stem

Limbic System

Right Hemisphere

Left Hemisphere

Dorsolateral Prefrontal Cortex

Emotions as Evolutionary DrivesEach emotion motivates different action:§ Anger: to fight, create boundaries, advocate for needs§ Guilt: to make behavioral changes, make amends with others§ Fear: to flee, avoid danger§ Sadness: to let go, to reach out to others to manage loneliness§ Joy: to connect to others, share excitement, celebrate, thrive

Healthy humans experience these emotions and act on them.

Shame is an emotion that shuts all the other emotions down. § Shame: to withdraw; prevents emotion from informing action§ Shame causes people to feel unworthy and apathetic.

Regulation TheoryHOW THE BODY MANAGES THREAT

The Polyvagal TheoryThe Polyvagal Theory proposes that:§ The sympathetic nervous system (mobilizing energy state) and the parasympathetic nervous system

(immobilizing energy state) are modified by the social engagement system (balanced energy state).

The body’s first response is to use the energy state of social engagement to manage stress.

When this does not work, the autonomic nervous system amps up and enters the energy state of fight/flight/fix.

If fight/flight behaviors do not resolve the issue, the autonomic nervous system shuts down and enters the energy state of immobility.

The Polyvagal Stoplight

Immobility

Fight/Flight/Fix

Social Engagement

The Polyvagal Theory

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Fight/Flight/Fix

Immobility

Social Engagement(Window of Tolerance)

The Polyvagal Theory and Emotion

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Fight/Flight/Fix

Immobility

Social Engagement(Window of Tolerance)Individual experiences

boundary violation.

Individual successfully uses self-assertion to recreate boundary.

Energy is discharged; individual returns to social engagement.

Regulating Defenses

Affiliation Dealing with emotional conflict or stressors by turning to other for help or support

Altruism Vicarious but constructive service to others

Anticipation Realistic planning

Humor Expression of affects without personal discomfort or poor effect upon others, in contrast to wit, which is more aggressive

Internalization A shift in functioning to promote flexibility in handling internal and interpersonal states

Self-assertion Expressing feelings and thoughts directly in a way that is not coercive or manipulative

Self-observation Reflecting on own thoughts, feelings, motivation, and behavior and responding appropriately

SublimationChanneling potentially maladaptive feelings or impulses into socially acceptable behavior, rather than damming up or diverting them, leading to modestly satisfying results

SuppressionDecision to postpone focus on conflict or situation, intentionally avoiding thinking about disturbing problems, wishes, feeling,or experiences

Trauma and Triggering Moments

Defining TraumaDefinition of Trauma:§ A traumatic event can be described as any experience that overwhelms someone.§ Trauma is an experience that is perceived to be a threat to life in the face of powerlessness (Scaer,

2014).§ The defining mark of trauma is a perceived sense that the individual can do nothing to change the

circumstances of the event.§ The evolutionary drives created by emotions become ineffective, rendered pointless by the lack of

power to influence the situation.

The Polyvagal Theory and Trauma

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Fight/Flight/Fix

Immobility

Social Engagement(Window of Tolerance)Individual experiences

boundary violation.

Individual is unable to use regulating defenses to recreate boundary.

Energy must be shut down; body numbs pain and inhibits memory.

Mobilizing Defenses

Acting out/regressionDirect expression of impulses that reflect unawareness of wishes or affect that accompany them; moving back to earlier developmental stage

Mania Flight from internal reality to external reality, denial of depression

ControllingManaging external events as substitute for (avoidance of) emotionally managing internal experience

ObsessivenessAttempting to ignore or suppress thoughts, impulses, or images or to neutralize them with some other thought or action

Delusions & Hallucinations Positive symptoms (active) psychotic conditions Omnipotence

Feeling or acting as if one possesses special powers or abilities and is superior to others

DerealizationAn alteration in the perception of experience of the external world so that it seems strange or unreal Projection Attributing qualities of the self to another

DevaluationInflated sense of self maintained by degrading representations of others Psychotic denial Refusing to acknowledge and negating what is seen, heard

DistortionEmploying sustained feelings of delusional superiority or entitlement Rationalization Expressing the opposite of the impulse

ExternalizationActively experiencing parts of one’s own personality in the external world Reaction Formation

Substituting behavior, thoughts, feelings that are opposite to own unacceptable thoughts and feelings

Help-rejecting complaining

Repetitiously requesting help in a way that disguises covert feelings of hostility or reproach, which are then expressed by rejecting the help offered

RepressionRemoves disturbing wishes, thoughts, or experiences from conscious awareness; however, the feeling may remain conscious

HypochondriasisTransformation of reproach toward others into self-reproach by drawing attention to physical complaints Sexualization

Assigning an object or function with sexual significance to not feel anxiety over prohibited impulses

IdentificationAssuming the actions of another; incorporation and introjection are considered primitive forms of identification, similar to imitation

Splitting Mixed feelings cannot be experienced simultaneously

Identification with the aggressor

Identifies not with the person of the aggressor, but with the aggression Somatic Reactions

Bodily reactions to experiences that become imprinted in neural circuitry

Idealization Attributing exaggerated positive qualities to others UndoingMaking amends symbolically for unacceptable thoughts, feelings, or actions

Immobilizing Defenses

AsceticismGratification derived from renunciation of pleasure

InhibitionRenouncing certain function to avoid anxiety from various sources of conflict

Autistic FantasyDaydreaming as substitute for relationships, action, or problem solving

Intellectualization

Thinking about rather than feeling affect to defend against anxiety from unacceptable impulses; excessive use of abstract thinking, making generalizations to control or minimize disturbing feelings

Blocking Inhibition of thoughts and impulses Introjection

Diminishes anxiety over ambivalence regarding separation from loved one or anxiety over feared other; isolation of affect or splitting affect from content, resulting in unawareness of either idea or affect

Denial Minimizing experience by lack of awareness Passive-AggressionA passive set of behaviors; indirectly and unassertively expressing aggression toward others

DisplacementSolving conflict by assigning impulse to different person/situation than original one (avoiding)

RepressionMoving from conscious awareness of an idea or affect to avoid anxiety

DissociationDrastic modification of personal identity to avoid emotional distress; dissociation involves a numbing of responsivity

Schizoid Fantasy Fantasy and autistic retreat to resolve conflict

Neural Integration and Trauma

Dysregulation disrupts communication between parts of the nervous system, preventing the energy and information of the evolutionary

drive from reaching the dorsolateral prefrontal cortex.

This prevents the individual from taking action.

The body learns that this shutdown dysregulation is the best – and only – way to

cope with the trauma.

Brain Stem

Limbic System

Right Hemisphere

Left Hemisphere

Dorsolateral Prefrontal Cortex

Triggering Event§Definition of Triggering Event (i.e. a trigger):§ A triggering event is any experience that reminds the client of the past traumatic experience. § Because the traumatic and triggering events seem alike, the client begins to experience the current

event in the same way that the traumatic event was experienced. § Just like the traumatic event overwhelmed the client, the client feels powerless to resolve the triggering

event.

The Polyvagal Theory and Triggering Events

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Fight/Flight/Fix

Immobility

Social Engagement(Window of Tolerance)Individual experiences

boundary violation.

Individual is unable to use regulating defenses to recreate boundary.

Energy must be shut down; body numbs pain and inhibits memory.

Triggering Events§ When triggered by a similar experience, the body

(brain stem/limbic system) understands that the trigger feels similar to the trauma.

§ Yet, the reasoning part of the brain (PFC) cannot make this connection as it was separated during the original trauma.

§ Consequently, at the logical level, the person understands that the trigger is happening in the present. However, the body re-experiences the trauma from the past.

§ This can help us understand why seemingly “benign” experiences can be experienced by the client as traumatic.

Brain Stem

Limbic System

Right Hemisphere

Left Hemisphere

Dorsolateral Prefrontal Cortex

Triggering Moments in Session § As clients discuss events from the present, their bodies can enter into autonomic

dysregulation just as they did during the trauma.

§ These moments are important in therapy as they present useful information about the trauma.

§ If a clinician can recognize these moments in session, she/he can then work to connect the present triggering situation to past trauma.

§ The goal of this connection is to help the client use regulating defenses to discharge the evolutionary drive that was left unresolved during the original trauma.

Cancer Diagnoses, Traumas, and Triggers

Cancer Diagnoses as TraumaBy definition, cancer diagnoses are considered traumatic.

Individuals, as well as their friends and families, are powerless to influence this event.

Often patients will become numb and shut down, experiencing a “do what I have to” mentality, or even becoming apathetic.

They may also become angry, guilty, scared, or sad. If the patient is able to experience these emotions, it is actually more adaptive for the individual.

Cancer Diagnoses as TriggersCancer diagnoses can elicit triggering moments in two ways.

1. Diagnoses can elicit past traumas (i.e. any event that created powerlessness).

2. Diagnoses can cause patients to become triggered in the future by any event that is perceived as similar to the initial diagnosis (e.g., treatment visits, medical tests – even if the cancer has been in remission for many years).

Treatment GoalThe goal for treating trauma is to integrate the unresolved emotions elicited during the original event.

A triggering moment provides an opportunity to learn about the past trauma, determine what was unresolved from the original event, and to take action to resolve the original evolutionary drive.

This facilitates neural integration in a way that could not occur during the original trauma due to dysregulation in the nervous system.

Feel to Heal™TRAUMA ASSESSMENT AND TREATMENT MODEL

Foundational Research

§ Interpersonal Neurobiology – Dan Siegel§ Regulation Theory – Allan Schore§ The Polyvagal Theory – Stephen Porges§ Sensorimotor Psychotherapy® – Pat Ogden§ Somatic Experiencing (SE™) – Peter Levine§ Trauma Soma – Robert Scaer

When Cancer is the “First” Trauma

Treatment GoalCancer is a trauma; it does not matter if it’s related to past traumas.

When clients use dysregulating defenses to manage emotion, the treatment goal is to help them use more adaptive coping strategies to facilitate neural integration.

For example, a client who acts out his anger, the goal would be to help him use self-observation, affiliation, anticipation, and self-assertion to manage his anger.

For a client who denies the impact of the cancer diagnosis on her life, the goal is to help her use self-observation, affiliation, anticipation, and self-assertion to manage her emotions.

Short Term TherapySPECIAL CONSIDERATIONS

Short-Term TherapyPotential short term goals:

◦ Psychoeducation◦ Regulation Practices◦ Social Engagement

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