tsr training for veterans david a fohrman, m.d.. what is tsr training? traumatic stress resiliency...
TRANSCRIPT
TSR Training for Veterans
David A Fohrman, M.D.
What is TSR Training? Traumatic Stress Resiliency (TSR) Training is
a program to teach you how to avoid getting PTSD Essential to Have Easy to learn
Takes about 30 minutes
What is the Problem? Veterans have a high risk for getting Post Traumatic
Stress Disorder (PTSD) Veterans also on active duty
In national guard or reserves For example, approximately 30% of the OIF/OEF veterans have
impaired due chronic PTSD symptoms With each deployment, the number goes up
Veterans have a 90% of experiencing a non-military related traumatic event These traumas can lead to PTSD higher risk if already have PTSD, from combat or non-combat
related experiences had a traumatic brain injury (TBI)
What is the Problem? PTSD symptoms (such as flashbacks, nightmares,
chronically feeling jumpy, irritable, angry, anxious or depressed) cause serious problems at work, home, in life
Lose job, marriage, friends, interests, life (suicide)
PTSD can be very difficult to treat especially chronic PTSD (having PTSD symptoms for
more then six months)
What is the Solution? Prevent PTSD before it develops Diagnosis of PTSD
Wait at least 30 days after traumatic/stressful situation ends In case of a deployment, time closer to 3-6 months
If symptoms resolve prior to this window, will not get PTSD If you already have PTSD from prior
deployments/non combat related traumatic situations, TSR training can still help
TSR Training Helps avoid road blocks that keep your body
from naturally recovering from the effects of traumatic events.
Two parts #1: What is PTSD #2 What are the six road blocks to recovery and
how can we avoid getting them
What is PTSD? PTSD is biological problem
A disorder due to our brain’s creating abnormal trauma induced memories.
These memories cause you to experience almost all of the symptoms of the symptoms of PTSD
Intrusive recollections of trauma Avoidance and numbing symptoms Hypervigalence and hyperarousal symptoms
Biological reason for PTSD SymptomsSymptoms of PTSD Biological reason
Keep thinking about event even when do not want to, flashbacks, nightmares
Memory system automatically reactivates event so it can re-process these abnormal, trauma memories
Can't remember important events, 'space out' under stress or dissociate
When experience high levels of emotions, voluntary part of memory system temporally turns off
Chronically feel anxious, nervous, or 'on edge' or unsafe: like we are in a potentially dangerous situation.
Trauma memories are not only sights and sounds, but are also the extremely strong negative emotions (such as fear and helplessness) you felt during the event.
Difficulty concentrating, difficulty falling and staying asleep, frequently feeling irritable, and easily startled.
Trauma memories activate our flight or fight response – chronically doing this make us have difficulty falling and staying asleep, frequently feel irritable and causes us to startle easily
Body’s Memory System
What is PTSD? PTSD is a spiritual problem
A disorder due to the creation of abnormal trauma induced faulty beliefs
Traumatic events can cause people to lose previously held core beliefs Core beliefs are things you believe to be true but don’t think about
Examples are when I go through a green light other drivers will obey the traffic signal and stop
When I really need help, people I trust will help me out.
As a result of trauma, people can become lose their self confidence, not trust other people, become very cynical, think everything is ‘worthless or meaningless’ and/or may lose previously held religious beliefs
What is PTSD? PTSD is a disorder due to a failure to naturally
recover from the effects of trauma All traumatized people temporality have some symptoms
of PTSD People get PTSD when they are unable to naturally
recover They don’t recover because trauma creates six road
blocks to recovery Soldiers have not been taught how to avoid these
roadblocks.
Six Roadblocks to Recovery#1 – Can’t feel safe
#2 – Can’t relax
#3 – Emotionally isolate self
#4 – Unable to stay in optimal zone for recovery
#5 – Avoid talking about trauma
#6 – Unable to fix trauma created faulty beliefs
Six Steps to Recovery Use mnemonic: GROWTH
G – Go to a Safe place R – Relax O – Open Up W – Wait until you are ready T - Tell your story H - Heal
GROWTH: Go to a Safe Place Feelings safe means feeling both physically
and psychologically safe
Physically safe – feel will not be unexpectedly hurt or killed
Psychologically safe – feel will not be taken advantage of while experiencing strong negative emotions
GROWTH: Go to a safe place Examples,
At home With friends Doing an activity you enjoy
If you are doing something you enjoy, you feel safe Can use handout to help you figure out what is a safe
place for you
Roadblock #1: Don’t feel safe Traumatic events can make us chronically
feel unsafe Like we might unexpectedly be in a life
threatening situation may sit with back against wall in restaurants Avoid or really dislike crowds
For those that have never experienced this feeling Like not having enough oxygen
Very hard to do anything other then try to feel safe
Avoid Roadblock #1: Don’t feel safe Regain sense of safety after trauma.
Practice gradual exposure technique When something makes us feel afraid one of two
things happen We freak out, panic, feel horrified, helpless, etc. We stay in control; with time, anxiety will go away
Each time we stay in control will feel less and less anxious
anxiety
time
GROWTH: Relax May think of one goal for relaxation:
‘de-stress’
Two Goals: 1. contain excessive emotion 2. regain a sense of being in control
Roadblock #2: Can’t relax Traumatic events can make it hard to relax
Chronically activate fight or flight response Feel anxious nervous, increase heart rate, blood
pressure, dilate pupils Can’t relax while fighting or running away!
Trauma are events where things are “out of control” Can chronically feel this way
Avoid Roadblock #2: Can’t relax Relax after trauma by having relaxation techniques that work for you
Can use breathing technique, described in handout Use any other technique that works
Literally hundreds of books in library, book stores Can use tapping technique to make flashbacks go away
Make sure you can feel in control “again” after trauma Figure out what you enjoy doing
Hobby, sport, work, being a parent, Do this in “easy way” after trauma to help you feel in control again.
Can use relaxation techniques to help with prolonged exposure
GROWTH: Open up Collectively, we can emotionally deal with
what we can not deal with alone True both in military and civilian settings
Enemies that are emotionally resilient are very difficult to beat Examples are soldiers during war of Independence
True psychologically and biologically!
Roadblock #3: Emotionally Isolate Self Traumatic events are situations were people close to
us can be hurt or killed. When this happens there is a natural tendency to
emotionally pull back For a limited period of time
Like having a rubber band snap on ones fingers More cautious next time
Problem: people choose to constantly isolate self minimize emotional contacts
Avoid Roadblock #3:Emotionally Isolate self
Use handout: Suggestions for Opening Up First talk about Easy Topics Then talk about more difficult topics
Talk about the what, where, when, how for each topic
GROWTH: Wait until you are ready Wait until you are ready
You need to be in your “optimal zone for recovery” before continuing
If you are below your optimal zone – your brain will not process memories This happens when you drink alcohol, use drugs or actively
avoid thinking about the trauma
If you are above your optimal zone, you will not re-process your abnormal trauma induced memories which will make it harder to fix them in the future
Avoid Roadblock #4: Can’t fix abnormal trauma memories
When your ready to recover, make you’re you are in your “optimal zone for natural recovery” Some people are ready to start recovering a day or two
after the event, others wait weeks or a couple of months Use the handout: Optimal Zone for Recovery” to
make sure your brain is biologically in the right place before you talk about the trauma with someone else. Doing this will increase the speed in which your brain
will fix it’s abnormal trauma induced memories
Optimal Zone for Recovery
Level of activation
Level of Emotion Thoughts Body symptoms
Too high/ Not able to concentrate
Excessive: extreme fear, panic, helplessness, rage, despair, shock, horror, extreme feelings of guilt, shame or self loathing
“ I am going to die!”“Help! I am trapped”“I can’t think!” “It’s never going to end!”“Things are out of control!”
Feel very nervous/anxious panic stricken. Chocking sensation/difficulty
breathingChest pain, dizziness, tingling around
mouth, in fingersSevere pain in abdomen, headache
Get stuck in flashback
Optimal Zone for recovery Optimal Level of emotionSadness, tearfulness, irritation, frustration, thoughtfulness, concern, agitation and low levels of anxiety and nervousness
“I don’t like how I am feeling but I Know I can feel this way and still be ok” “I am feeling irritated/sad/concerned/ etc right now” “Feeling this emotion (put in emotion) is hard but I think this is helping”
Feel awake, focused and aware of your surroundings
Heart beating a little fasterBreathing faster
More aware of sights, sounds, smells, May have some feelings connected to
flashback experience
Too low/ not interested enough to concentrate
Little or no emotional reaction to the topic or mild
irritation
“I’m bored”“This is waist of time”“I would rather …. (be doing (something else)
no symptoms
Handout Your optimal Zone for Recovery
Level of activation Level of Emotion Thoughts Body symptoms
Too high/ Not able to concentrate Excessive: extreme fear panic helplessness rage despair shock, extreme feelings of guilt, shame or self loathing other:_____________ other:_____________
“ Get me out of here!” “Help! I am trapped” “I can’t think!” “It’s never going to end!” “Things are out of control!” other:_______________ other:_______________
Chocking sensation Difficulty breathing Chest pain Severe nausea dizziness, tingling around mouth, in fingers pain in abdomen, severe headache other:_______________ other:_______________
Optimal Zone for Recovery Optimal Level of emotionSadness, tearfulness, irritation, frustration, thoughtfulness, concern, agitation and low levels of anxiety and nervousness other:_____________ other:_____________
“I don’t like how I am feeling I Know I am going to be ok”
“I am feeling irritated”I am feeling sad
I am feeling concerned other:_____________ other:_____________
Feel awake, focused and aware of your surroundings
Heart beating a little fasterBreathing faster
More aware of sights, sounds, smells, May have some feelings connected to
flashback experience other:_____________ other:_____________
Too low/ not interested enough to concentrate or wish to actively
avoid thinking about
Little or no emotional reaction to the topic
mild irritationsense of vague anxiety other:_____________ other:_____________
“I’m bored” “This is waist of time” “I would rather …. (be doing (something else) other:_____________ other:_____________
no symptoms mild nausea sense of unease other:_____________ other:_____________
GROWTH: Tell your story The best way to recover from the effects of trauma is to talk about it Name for this: Natural Debriefing
Teaches you how to naturally debrief Something we do often do after a stressful day
We talk to a spouse/significant other or a loved one Talking doesn’t change ‘what happened”
Still, we feel better
In case of trauma Talking also helps brain re-process trauma created abnormal memories Easier said then done
We don’t practice talking about trauma Trauma usually a rare event
Something people keep to themselves
Roadblock #5: Avoid Talking about trauma
Traumatic events bring up: very strong emotions like horror, helplessness,
intense fear, anger, shame, guilt Thoughts, beliefs about ourselves, others or the world
that are very distressing “It was my fault” “I can’t trust anyone because of what happened’
Natural not to want to talk about, let alone think about, these things
Avoid Roadblock #5: Avoid talking about trauma
Practice by: First thinking of something that bothers you
if have a hard time, think of a time when you “over reacted’ to something – for example, became angry for little or no reason
think about something that irritates you; bothers you only a little write down, in outline form, what happened
use handout: Tell your story for an example tell this story to someone else
if feel overwhelming emotion, stop main thing is the process does not matter how long you speak as long as you stay
emotionally in control
Session #6: Heal
Healing occurs when your past traumas no longer holds you back from living your live
the fullest Healing occurs in two ways: Biologically, Spiritually
Biologically reprocess abnormal trauma induced memories
Spiritually Fix any trauma induced faulty beliefs
Heal Biologically
Process abnormal trauma induced memories Stop uncontrolled reactivation of event,
flashbacks, etc. Stop excessive fight or flight activation
Stop startle reaction, irritability, hypervigalence
Heal Biologically Fill out the PTSD symptom checklist, any
symptom you have more then ‘rarely’ is a positive response
If you have any positive response, use the GROWTH technique to help make these symptoms go away.
If you still have symptoms for more then two months after using these techniques, get additional help! PTSD can be very difficult to treat!
Heal Spiritually Trauma causes us to lose things important to us
Both concrete/specific and beliefs This causes us to:
disconnect with ourselves “live in your head” and become excessively stoic
disconnect with others Emotionally as well as physically
disconnect with our beliefs/ideals Start questions basic/or long held secular and/or religious beliefs
Heal – reconnect to yourself Identify if you are disconnected
Difficulty experiencing/expressing intense emotions Experience unexplained medical problems
Heal by being able to experience emotions without getting overwhelmed By body sensations Thoughts
Recover from unexplained/stress induced medical problems Especially gastrointestinal, headaches, other unexplained aches and
pains Sexual dysfunction
Need to be able to express intimacy and aggression
Heal – reconnect to others Identify if you are disconnected
Physically isolating oneself Emotionally isolating oneself/avoiding emotional
intimacy Honestly/behavior will tell you if this is an issue
What would an ‘fly on the wall’ say you are doing
Often held back in emotionally reconnecting because of our trauma induced beliefs
Heal -reconnect to your beliefs
Before being traumatized(1) I am in control of my life(2) I am competent.(3)I can reach my goals
(4) What I think, feel, say and do effects other people
(5)I can control how I spend my time(6) I am usually pretty healthy person
After being traumatized(1)My life is out of control (2)I am basically incompetent. (3) I can’t accomplish what I set out
to do(4)My actions, thoughts, and feelings
do not affect any one but me(5) I can not take control of how I
spend my time(6) I am usually sick
Handout - Identify if you have trauma induced beliefs
Heal re-connect to your beliefs Use questioning of beliefs as an opportunity to growth
Other cultures view trauma as a rite of passage Opportunity to grow
Researchers have a name of this: Post Traumatic Growth As a result of living through a potentially life threatening event,
people often report they now ‘try to live each day to the fullest’ ‘do things (like hobbies, going on vacations, etc.) that they had put off
doing before’ ‘feel that their life is more meaningful’ ‘are closer to their friends and family’
Pragmatically – emphasize decision to prioritize “connecting”
Change your actions, change your life Use OIA acronym.
Observe Imagine Act
Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to examples: spouse tries to talk to you, you pretend not to hear him/her first identify situation retrospectively, then Use OIA acronym.
Observe Imagine Act
Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to examples: spouse tries to talk to you, you pretend not to hear him/her first identify situation retrospectively, then
Imagine Imagine – how you would act if you wanted
to emotionally connect example – spouse talks to you, you listen
Use active listening skills We all have them, but don’t always use them
Identify at what stage of moral development client is – speak to them at that level
Practice scenarios that could happen
Act Act as if you want to emotionally and physically
connect This may or may not be connected to your current
beliefs May be an ‘act of faith’
Faith means different things This is secular
Refers to acting in a way you hope (or wish) were true even though you may not belief it’s true
Act first, and your beliefs will follow
Final points Trauma happens!
PTSD and other long term post trauma problems don’t have too
Can use GROWTH to help you and your loved ones recovery from the psychological effects of deployment.
G - Go to a safe place R - Relax O - Open up W - Wait until you are ready T - Tell your story H - Heal