Understanding

Trauma and

Effective Trauma

TreatmentKristan Warnick, MS, CMHC

• Healing Pathways Therapy Center -Owner

• Trauma Informed Care Network of Utah - Founder

University of Utah

Goodwill Humanitarian Building

395 South 1500 East, SLC UT

AGE NDA

7:30-8:00

Registration

8:00--2:00

Keynote Plenary Sessions

1:00--4:15

Afternoon Plenary Sessions

4:15 to 4:30

Wrap up & Evaluation

(Attendance is Free )

A free educational

training for community leaders and members on the long-term effects of trauma across the life

span, and why it is imperative for the

community to become aware of the warning signs and intervene.

Health and Resilience Symposium: Growing a Trauma Informed Community

Violence, Abuse and other Toxic Stressors across the Lifespan

A free educational

training for community leaders and members

AGENDA 8am-4:30pm 7:30 AM REGISTRATION 8 AM WELCOME 8:10-11:15 AM MORNING SESSION 11:15 AM – 12:15 PM LUNCH PROVIDED 12:15 PM AFTERNOON SESSION 4:20 PM WRAP-UP AND

EVALUATION

October 15, 2014

LOCATION: UNIVERSITY

OF UTAH GOODWILL

HUMANITARIAN

BUILDING 395 S 1500E HTTP://WWW.MAPQUEST.COM/MAPS?ADDRESS=395+S+1500+E&CITY=SALT+LAKE+CITY&STATE=UT&ZIPCODE=84112&REDIRECT=TRUE

COLLEGE OF SOCIAL WORK

A free educational

training for community leaders and members

COMMUNITY PARTNERSHIPS

WELCOME: THE TIME IS NOW FOR A TRAUMA-INFORMED CARE COMMUNITY Susie Wiet, MD (Chair) Assistant Professor (adjunct faculty), Psychiatry, at the University of Utah School of Medicine; Director of Psychiatric Services at Odyssey House of Utah, Founder of the steering committee for this symposium.

MORNING SECTION: NATIONAL BOARD MEMBERS OF THE ACADEMY ON VIOLENCE AND ABUSE (AVA) THE ADVERSE CHILDHOOD EXPERIENCE STUDY (ACES): IMPLICATIONS OF LONG-TERM EFFECTS

Randy Alexander, MD, PhD Clinical Professor, Pediatrics, at the University of Florida, College of Medicine, Medical Director of Florida’s Child Protection Team, Chief of Division of Child Protection and Forensic Pediatrics, President-Elect of the AVA

NEUROBIOLOGICAL CHANGES FROM TOXIC STRESS Brooks Keeshin, MD Assistant Professor, Pediatrics Division of Child, Protection and Family Health at the University of Utah School of Medicine, board member of the Academy on Violence and Abuse.

INTER PARTNER VIOLENCE: A NECESSITY TO IDENTIFY Kathy Franchek-Roa, MD Assistant Professor, Pediatrics, University Of Utah School of Medicine, Chair of the Utah Domestic Violence Coalition Health Care Workgroup, Chair of the University of Utah Health Care Domestic Violence Task Force.

EDUCATING THE COMMUNITY: HEALTH IMPACT OF VIOLENCE AND ABUSE Dave Corwin, MD Professor and Director of Forensic Services, Pediatrics Department at the University of Utah School of Medicine, President, AVA; Secretary American Professional Society on the Abuse of Children

AFTERNOON SESSION: LOCAL EXPERTS, SURVIVORS AND AGENCIES STARTING IN CHILDHOOD

Brian Miller, PhD (The Children’s Center) Director of The Safety Net Program for Families with Young Children Carol Anderson, Med (Utah State Office of Education) Education Specialist, Behavioral Supports/Mental Health Needs

ADULTS BEAR THE LONG-TERM COSTS Steve Allen, PhD (Veterans Affairs Medical Center) Post-Traumatic Stress Disorder Clinical Team Director Kristan Warnick, CMHC (Healing Pathways Counseling, founder) Founder of the Trauma-Informed Care Network of Utah

PANEL DISCUSSION: TRAUMA IN THE COMMUNITY AND PREVENTION Trina Taylor (Executive Director) Prevent Child Abuse – Utah Kami Peterson MS RN CBPN-IC (Public Health Nursing Bureau Manager, Family Health Services) Salt Lake County Health Department Renee Olesen, MD (pediatrician) American Academy of Pediatrics-Utah Chapter Mark Manazer, PhD (Chief Operating Officer) Volunteers of America of Utah

PANEL DISCUSSION: SURVIVORS OF TRAUMA AND LONG-TERM RECOVERY Four panelists discuss their journey through community services and systems as a victim of trauma and/or violence

PANEL DISCUSSION: AGENCIES INTEGRATING PRINCIPLES OF A TRAUMA INFORMED COMMUNITY Nanon Talley, LPC (State Training Manager) Utah Division of Child and Family Services Lisa Arbogast, MEd, JD (Coordinator of Law and Policy, Special Ed) Utah Board of Education David Sundwall, MD (Professor of Public Health) University of Utah School of Medicine, Division of Public Health, former director of the Utah Department of Health Doug Thomas, LCSW (Director) Utah Division of Substance Abuse and Mental Health TBA: Utah Department of Workforce Services

Understanding Trauma

What is trauma? Definition

Psychological trauma is a type of

damage to the psyche that occurs as a

result of a severely distressing event.

Trauma, which means "wound" in Greek, is

often the result of an overwhelming

amount of stress that exceeds one's ability

to cope or integrate the emotions

involved with that experience. - Wikipedia

What is Trauma?

Trauma is a lasting psychic wound that does

not easily resolve on it’s own - Not all bad

experiences lead to trauma and not all

trauma comes from experiences that are

seemingly traumatic.

How to Identify Trauma

Observation/Interviews

Client disclosure

DSM-V Diagnosis

Questionnaires – about trauma and

trauma symptoms

EMDR protocol is diagnostic

Observations/Interviews Clients are stuck in negative thoughts, emotions,

body sensations

Clients don’t respond to traditional talk therapy

Teaching skills and awareness doesn’t seem to be

enough

They understand intellectually but can’t move

past it emotionally

They are emotionally flooded or numbed out

Dissociative symptoms

Other?

PTSD DSM-V DiagnosisSome Key Changes in DSM-V

moved from the class of anxiety disorders into a new class of "trauma and stressor-related disorders.”

require exposure to a traumatic or stressful eventas a diagnostic criterion. The rationale for the creation of this new class is based upon clinical recognition of variable expressions of distress as a result of traumatic experience.

A clinical subtype "with dissociative symptoms"was added

Separate diagnostic criteria are included for children ages 6 years or younger

Some debate about

whether the DSM-V definition

is too wide or too narrow

Problems with the post-traumatic stress disorder diagnosis

and its future in DSM–V Gerald M. Rosen, PhD, Robert L.

Spitzer, MD, Paul R. McHugh, MD

http://bjp.rcpsych.org/content/192/1/3.long

Criterion A: stressor - The person was exposed to: death,

threatened death, actual or threatened serious injury, or

actual or threatened sexual violence, as follows: (one

required)

Direct exposure.

Witnessing, in person. Indirectly, by learning that a close relative or close friend

was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.

Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: intrusion symptoms - The traumatic

event is persistently re-experienced in the

following way(s):

Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play.

Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).

Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.

Intense or prolonged distress after exposure to traumatic reminders.

Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: avoidance - Persistent effortful

avoidance of distressing trauma-related

stimuli after the event

Trauma-related thoughts or feelings.

Trauma-related external reminders (e.g.,

people, places, conversations, activities,

objects, or situations).

Criterion D: negative alterations in cognitions and mood - Negative alterations in cognitions and mood

that began or worsened after the traumatic event:

Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).

Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous").

Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.

Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).

Markedly diminished interest in (pre-traumatic) significant activities.

Feeling alienated from others (e.g., detachment or estrangement).

Constricted affect: persistent inability to experience positive emotions.

Criterion E: alterations in arousal and reactivity -Trauma-related alterations in arousal and reactivity that

began or worsened after the traumatic event

Irritable or aggressive behavior

Self-destructive or reckless behavior

Hypervigilance

Exaggerated startle response

Problems in concentration

Sleep disturbance

Specify if: With dissociative symptoms.

Depersonalization: experience of being

an outside observer of or detached from

oneself (e.g., feeling as if "this is not

happening to me" or one were in a

dream).

Derealization: experience of unreality,

distance, or distortion (e.g., "things are not

real").

Full diagnosis is not met until at least six

months after the trauma(s), although onset of

symptoms may occur immediately.

We should not wait to treat, as research has shown that immediate trauma work can help alleviate symptoms

EMDR Humanitarian Assistance Programs (HAP) http://www.emdrhap.org

An assessment of the impact of direct volunteer services provided after the terrorism attacks in New York City demonstrated the effectiveness of both immediate and delayed EMDR treatment (Silver et al., 2005).

Clinicians trained by HAP treated victims of the Marmara, Turkey earthquake in tent cities, and demonstrated that 92.7% of a representative sample of 1,500 of those with PTSD lost the diagnosis after an average of five 90-minute EMDR sessions, with a reduction in symptoms in the remaining participants (Konuk et al., 2006).

Hurricane in Mexico - EMDR group treatment protocol was developed (Jarero et al., 1999) that has now been used worldwide with great success. Rapid treatment effects have been demonstrated after 1-4 sessions in interventions throughout Latin America, in Italy, and in the Palestinian territories (Adruiz et al., 2009; Fernandez, Gallinari, & Lorenzetti, 2004; Jarero et al., 2006, 2010; Zaghrout-Hodali et al., 2008).

Broader Definitions of Trauma

Big T Trauma – classic DSM-IV diagnosis, ACES, obvious traumatic experiences, sometimes these are resolved quickly

Example

Client who was a hospice nurse

came home in the afternoon to hear her daughter dying on the couch, making the “death rattle”.

healthy functioning woman previously, had panic and anxiety and couldn’t go home at that time in the afternoon for months afterwards.

Took 3 sessions to resolve

Little T Trauma or “Subtle Trauma”

Any other type of event which exceeds our capacity to cope, and can be stored as trauma. Examples can include divorce, job loss, an abrupt move, really anything that overwhelms us.http://blogs.psychcentral.com/after-trauma/2014/02/the-big-deal-with-little-t-traumas/

Example: 13-year-old nephew intense physical and emotional reactions to popcorn, sat far away from it in the movie theater, very agitated if

someone is eating popcorn near him. One EMDR session – traced back to father getting mad at

him for not completing homework and pushed his face in the popcorn bowl. My niece told me on Sunday he still doesn’t love popcorn but can stand being around it =).

Dr. Francine Shapiro Defines two types of trauma—“big T” trauma and “little t”

trauma. “Big T” trauma refers to what we commonly think

of as trauma like war or natural disaster, “little t” trauma

refers to incidents such as getting teased as a child or

getting rejected by your first love. Most people experience

“little t” trauma some time in their lives. People who live

with and love someone emotionally abusive experience

“little t trauma” on a daily basis. The experience of put

downs, criticisms or whatever form emotional abuse takes,

not only wears down self-esteem but also impacts the

nervous system. Memories of the abuse can elicit negative feelings, tense physical sensations along with negative

thoughts about yourself long after the abuse has occurred.

http://www.goodtherapy.org/blog/trauma-emotional-abuse/

Other Trauma TypesChronic Trauma – ongoing repeated trauma such as an alcoholic abusive father. Internalized feelings of anxiety, fear, unworthiness. Messages of “I’m not safe.”

Example –

young man in his 30’s unable to form healthy intimate relationships

angry mentally ill father

a string of step-mothers throughout his developmental years

Trauma work off and on for more than a year, developmentally delayed in relationships but making steady hopeful progress

Complex Trauma

Prolonged exposure to repetitive or severe events such as child abuse, is likely to cause the most severe and lasting effects. This often is a combination of several different types of trauma

.

Example: Woman in her 40’s struggling with severe depression,

anxiety, poor attachment, suicidal ideation, self-harm

Sexual, physical, emotional abuse from father, neglect from mother, molestation by father, then by several neighbors who she went to for help

In treatment for years, requires a lot of stabilization in the present, slow going on trauma work, but making progress over time, will continue to be delayed in her ability to attach and form intimate relationships

Traumas of AttachmentMany types of abuse/trauma can cause attachment issues but this also includes:

Childhood Neglect– a trauma of grief and loss, Traumatization can also occur from neglect, which is the absence of essential physical or emotional care, soothing and restorative experiences from significant others, particularly in children - http://www.isst-d.org

Example –

severely depressed female client whose father was numbed out from his WWII experience and mother who coped by working hard.

quiet, compliant oldest daughter who got very little affection, attention, praise, and learned to self-soothe with food

very low self esteem, poor self-efficacy, struggles to initiate activities, relationships, try new things. Complains of feeling bored and empty – time weighs heavily.

Very slow progress, but slowly making headway in awareness, letting go of negative beliefs, connecting to more positive thoughts, emotions, behaviors

Adult Attachment InjuriesEmotionally Focused Therapy – Sue Johnson Johnson, S.M., Makinen, J. & Millikin, J. (2001) Attachment Injuries in Couples Relationships: A New Perspective on Impasses in Couple Therapy. Journal of Marital and Family Therapy, 27, 145-156.

Example Couples client - wife was in labor in the hospital and the

husband went and played golf with friends. primed by childhood neglect to feely highly abandoned at

the time of attachment injury Has anxiety response when she thinks about this and it

affects her ability to feel safe and be intimate with her husband.

Can improve with individual trauma work and couples attachment injury work

Identifying Trauma through Formal Measures Adverse Childhood Experience Questionnaire

(ACES) Life Event Checklist

Trauma Checklist Adult

Trauma Symptom Inventory (TSI) - Briere, 1996 -global measure of trauma sequelae; items are not keyed to a specific traumatic event

Trauma Symptom Checklist – 40 (Briere & Runtz, 1989)

Child and Adolescent Trauma Measures – A Review - http://www.ncswtraumaed.org/wp-content/uploads/2011/07/Child-and-Adolescent-Trauma-Measures_A-Review-with-Measures.pdf

Negative side effects of unresolved trauma

See ACES study http://acestoohigh.com/got-your-ace-score/

A variety of health issues

Chronic Pain

Autoimmune – High Adrenaline - Adrenal Fatigue -Cortisol Response - Inflammatory Response

Anxiety

Depression

Non-responders to regular talk therapy

Panic attacks, phobias

More negative side effects of unresolved trauma Relationship dysfunction

Addictions

Personality disorders

Other mental health disorders

“Bipolar trauma disorder” – Colin Ross - http://www.rossinst.com

Internationally renowned clinician, researcher, author and lecturer in the field of dissociation and trauma-related disorders. He is the founder and President of the Colin A. Ross Institute for Psychological Trauma. Calls himself a former psychiatrist. I’m guessing he would also say Borderline Trauma Disorder.

Example: client was primed by death of her father as a preteen, then several incidents of molestation as a teenager, was diagnosed and put on med cocktail in college, subsequent adult rape. We did her trauma work and she no longer fits bipolar diagnosis. Off most of her previous meds.

How Trauma is StoredLimbic system – stores memories in form of negative

thoughts, images, sensations (sight, sound, smell,

body sensations)

The Theory Behind EMDR and the

Adaptive Information Processing Model

Humans have a physiologically-based information processing system - compared to other body systems, such as digestion in which the body extracts nutrients for health and survival.

Memories are linked in networks that contain related thoughts, images, emotions, and sensations

When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks.

The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed.

When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like she is reliving it, or may experience strong emotions and physical sensations.

Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in the future.

Solomon, R.M., & Shapiro, F. (2008). https://www.emdr.com/general-information/what-is-emdr/theory.html

Other Thoughts about Neurological Processes in Trauma

Disconnect from frontal lobe and limbic system –brain imaging has shown weaker links in traumatized individuals that actually strengthens as trauma resolution progresses

Right brain – emotional is disconnected from left brain – logical. EMDR helps coordinate left and right brain allowing logic override emotion.

Disintegration – vs – integration – trauma resolution creates adaptive neurological connections/links –the brain integrates the old information with new information and says A-ha and then can let go of the old trauma material

Trauma processing techniques such as EMDR put brain in healing state or theta state where this integration can happen

Understanding Trauma Management/Containment

– vs –Trauma Resolution/Release/Healing

Many therapies involve coping rather than healing

Both of these are important in the process of trauma resolution but it’s helpful for clients and clinicians to understand which is which. This alleviates frustration when coping techniques to not “cure” the problem

Many clinicians and clients today still believe that trauma or PTSD can only be managed rather than cured.

What can I do if I am a trauma-informed

therapist but not formally trauma trained?

A lot !!!!

Ask the questions – don’t be scared to bring it up, trust that you can help them contain emotion if they get triggered.

Administer ACES or similar questionnaires about traumatic events or symptoms or trauma symptoms

Ask “When is the first time or worst time you felt that way? – Quick diagnostic to see if current thoughts, feelings, emotions might tie into something from their past

Teach trauma containment techniques – make sure clients understand that these are skills to manage the trauma symptoms before or during trauma treatment, but that these won’t necessarily resolve the trauma, otherwise it can be frustrating and discouraging for them

Consider taking courses in a formal trauma treatment modality – good investment - marketable, will expand your client base, will help you better formulate and understand many if not most of your cases even if you don’t practice the modality, research shows EMDR therapists have higher job satisfaction, less burn out.

Trauma Management Techniques

Psycho-education/awareness about trauma

Healthy coping skills

Resources – develop social support, self-care, hobbies, spirituality, build on success experiences

Help clients identify and recognize triggers

Affect regulation

Relaxation techniques

Mindfulness

Trauma Management Techniquescont…

DBT skills– mindfulness, affect regulation, relationship skills Try to avoid dissociation in session – leads to re-

traumatization – keep one foot in the present – Are you here with me?

Container Exercises Grounding Exercises Know your limits – for both trauma informed and trauma

trained therapists Referrals to trauma trained therapists with appropriate

skills/specialization to meet clients needs Before, during, and after trauma treatment clients will need

to learn new skills such as assertiveness, communication, healthy risk-taking, etc.

EMDR Informed

Techniques

• Self Help Techniques

• Appropriate for clients and

clinicians

• Don’t need to be EMDR

trained to use these

Effective Trauma Treatment

Research-Based Trauma Modalities

Effective trauma resolution therapies should work with trauma material stored in the limbic system

Talk therapy often only accesses frontal lobe so more experiential, holistic, symbolic, multisensory methods tend to be more effective based on this model

Art Therapy, TF-CBT, EMDR, NLP, Play Therapy, Exposure Therapy, Energy work, Emotional Freedom Technique, Body work (chiropractic, massage, cranio-sacral)

Some of these tend to be seen as “alternative” without substantial research basis, but research support is growing in many of these areas.

Veterans Administration

Recommendations

Cognitive Behavioral Therapy (CBT), such as

Cognitive Processing Therapy (CPT)

Prolonged Exposure Therapy (PE)

Eye Movement Desensitization and

Reprocessing (EMDR)

Medications called Selective Serotonin

Reuptake Inhibitors (SSRIs)

http://www.ptsd.va.gov/public/treatment/therapy-

med/treatment-ptsd.asp

Therapy – vs - MedicationWhile there is no clearly defined “preferred” approach to manage PTSD, each of these guidelines supports the use of trauma-focused psychological interventions for adults with PTSD, and all recognize at least some benefit of pharmacologic treatments for PTSD. Indeed, some guidelines identify trauma-focused psychological treatments over pharmacological treatments as a preferred first step and view medications as an adjunct or a next-line treatment.

Jeffereys M. Clinician's Guide to Medications for PTSD. Washington, DC: United States Department of Veterans Affairs; 2011. Available at: http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-for-ptsd.asp.

NICE Guidelines. Available at: http://guidance.nice.org.uk/ (CG26). Accessed December 12, 2011.

Other Recommendations:Cognitive-behavioral therapy such as cognitive restructuring, cognitive processing therapy, exposure-based therapies, and coping skills therapy (including stress inoculation therapy); psychodynamic therapy; eye movement desensitization and reprocessing (EMDR); interpersonal therapy; group therapy; hypnosis/hypnotherapy; eclectic psychotherapy; and brainwave neurofeedback. These therapies are designed to minimize the intrusion, avoidance, and hyperarousalsymptoms of PTSD by some combination of re-experiencing and working through trauma-related memories and emotions and teaching better methods of managing trauma-related stressors.

Institute of Medicine. Treatment of PTSD: assessment of the evidence. Washington, DC: National Academies Press, 2008.

What is EMDR? An eight-phase treatment

Eye movements (or other bilateral stimulation) are used during one part of the session.

After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist's hand as it moves back and forth across the client's field of vision.

As this happens, for reasons believed to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings.

https://www.emdr.com/faqs.html

How Effective is EMDR?

Twenty positive controlled outcome studies have been done on EMDR.

Some of the studies show that 84%-90% of single-trauma victims no longer have post-traumatic stress disorder after only three 90-minute sessions.

Another study, funded by the HMO Kaiser Permanente, found that 100% of the single-trauma victims and 77% of multiple trauma victims no longer were diagnosed with PTSD after only six 50-minute sessions.

In another study, 77% of combat veterans were free of PTSD in 12 sessions. There has been so much research on EMDR that it is now recognized as an effective form of treatment for trauma and other disturbing experiences by organizations such as the American Psychiatric Association, the World Health Organization and the Department of Defense.

Phase 1: The therapist assesses the client's readiness and develops a

treatment plan. Client and therapist identify possible targets for EMDR

processing. These include distressing memories and current situations that cause emotional distress. Other targets may include related incidents in the past.

Emphasis is placed on the development of specific skills and behaviors that will be needed by the client in future situations.

Initial EMDR processing may be directed to childhood events rather than to adult onset stressors or the identified critical incident if the client had a problematic childhood.

Clients generally gain insight on their situations, the emotional distress resolves and they start to change their behaviors.

Phase 2:

The therapist ensures that the client has

several different ways of handling emotional

distress.

The therapist may teach the client a variety of

imagery and stress reduction techniques the

client can use during and between sessions.

A goal of EMDR is to produce rapid and

effective change while the client maintains

equilibrium during and between sessions.

Phases 3-6: A target is identified and processed. This involve the client identifying three

things: 1. The vivid visual image related to the memory 2. A negative belief about self 3. Related emotions and body sensations.

In addition, the client identifies a positive belief. The therapist helps the client rate the positive belief as well as the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation. These sets may include eye movements, taps, or tones. At this point, the EMDR client is instructed to just notice whatever spontaneously happens.

After each set of stimulation, the clinician instructs the client to notice whatever thought, feeling, image, memory, or sensation comes to mind. These repeated sets with directed focused attention occur numerous times throughout the session. If the client becomes distressed or has difficulty in progressing, the therapist follows established procedures to help the client get back on track.

When the client reports no distress related to the targeted memory, (s)he is asked to think of the preferred positive belief that was identified at the beginning of the session. At this time, the client may adjust the positive belief if necessary, and then focus on it during the next set of distressing events.

Phase 7:

In this phase of closure, the therapist asks

the client to keep a log during the

week. The log should document any

related material that may arise. It serves to

remind the client of the self-calming

activities that were mastered in phase two.

Phase 8:

Consists of examining the progress made

thus far. The EMDR treatment processes all

related historical events, current incidents

that elicit distress, and future events that will

require different responses.

ConclusionWe can manage AND heal trauma. It is complex yet rewarding work.

Posttraumatic phenomena and their permutations are rich in their tapestry and are woven of thousands of threads whose fibers are spun from unique and sometimes exotic, secretive, horrific, and forbidden sources of discovery.

Trauma work “on one end of the continuum…exacts an enormous toll on therapists, draining their inner empathic resources…at the other end is a realization of the human capacity for resilience and self-actualization, and the power of the human spirit to heal itself.

…Clinical moments of dedication, inspiration, hoped for wisdom through education and training alternate with private reflections of self-doubt, insecurity, despair, and fantasies of escape from the heavy professional responsibility entailed in this task (Wilson and Thomas, 1999).

Treating Psychological Trauma and PTSD. Edited by Wilson, J.P. Friedman, M.J., & Lindy, J.D. 2012 The Guilford Press, NY, NY.

References

Aduriz, M.E., Bluthgen, C. & Knopfler, C. (2009). Helping child flood victims using group EMDR intervention in Argentina: Treatment outcome and gender differences. International Journal of Stress Management, 16, 138-153.

American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: Author.

Fernandez, I., Gallinari, E., & Lorenzetti, A. (2004). A school- based EMDR intervention for children who witnessed the Pirelli building airplane crash in Milan, Italy. Journal of Brief Therapy, 2, 129-136.

Jarero, I., & Artigas, L. (2010). The EMDR integrative group treatment protocol: Application with adults during ongoing geopolitical crisis. Journal of EMDR Practice and Research, 4, 148-155.

Jarero, I., Artigas, L., & Hartung, J. (2006). EMDR integrative group treatment protocol: A post-disaster trauma intervention for children and adults. Traumatology, 12, 121-129.

Jarero, I., Artigas, L., López Cano, T., Mauer, M., & Alcalá, N. (1999, November). Children’s post traumatic stress after natural disasters: Integrative treatment protocol. Poster presented at the annual meeting of the International Society for Traumatic Stress Studies, Miami, FL.

Johnson, S.M., Makinen, J. & Millikin, J. (2001) Attachment Injuries in Couples Relationships: A New Perspective on Impasses in Couple Therapy. Journal of Marital and Family Therapy, 27, 145-156.

Konuk, E., Knipe, J., Eke, I., Yuksek, H., Yurtsever, A., & Ostep, S. (2006). The effects of EMDR therapy on post-traumatic stress disorder in survivors of the 1999 Marmara, Turkey, earthquake. International Journal of Stress Management, 13, 291-308.

Silver, S.M., Rogers, S., Knipe, J., & Colelli, G. (2005). EMDR therapy following the 9/11 terrorist attacks: A community-based intervention project in New York City. International Journal of Stress Management, 12, 29-42.

Solomon, R.M., & Shapiro, F. (2008). EMDR and the Adaptive Information Processing Model. Journal of EMDR Practice and Research, 2(4), 315-325.

Wilson, J.P., & Thomas, R. (1991) Empathic strain and countertransference in the treatment of PTSD. Paper presented at the 14th annual meeting of The International Society for Traumatic Stress Studies, Miami, FL.

Wilson, S., Becker, L.A., & Tinker, R.H. (1995). Eye movement desensitization and reprocessing (EMDR): Treatment for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63, 928-937.

Zaghrout-Hodali, M., Alissa, F. & Dodgson, P.W. (2008). Building resilience and dismantling fear: EMDR group protocol with children in an area of ongoing trauma. Journal of EMDR Practice and Research, 2, 106-113.

TICN News/Upcoming Events: October 3rd TICN – Anastasia Pollock – Ego State

Therapy, Internal Family Systems

November 14th TICN - Leslie Brown - Complex trauma, DID, more EMDR, more ego state, and polyvagal theory,

Health and Resilience Symposium: Growing a Trauma Informed Community – October 15th at U of U

Academy on Violence and Abuse - Conference on October 16-18 -http://www.avahealth.org/events/2014_members_meeting/

Critical Issues Conference – October 23-25th – trauma focus

EMDR training offered to non-profit therapists (20-30 hours per week in non-profit setting) in December through U of U Social Work Program and Rape Recovery Center