Daniel A. Glaser, MSW, LCSW SASH, 2014 “There may be times when I’m not certain of what to do, but there is never a time when I don’t know what not to do.” [Rogers, B. (2011). Addiction and Grief] Types of Safety Physical Safety Mental Safety Emotional Safety Spiritual Safety [Williams & Poijula (2012). The PTSD Workbook] Self Esteem Efficacy based > seeing oneself as competent and capable. Worth based > feeling that one is accepted and valued. [Stete & Burke, “A Sociological Approach to Self & Identity” in Leary & Tangney [eds.] Handbook of Self & Identity, 2003] Ability to be aware of, control and monitor emotional reactions, impulses, and behaviors. Ability to repair emotional distress, usually through taking control and renegotiating the environment. [Katehakis (2010). Erotic Intelligence] Steady State (“contextual normality”) Temporary relief (guilt, shame) Stress (“narcissistic injury”) Pseudo or symbolic intimacy (fusion or libidinal & aggressive forces) 1. Fear of fusion 2. Fear of exposure 3. Fear of rejection/abandonment 4. Fear of other’s aggressive impulses (annihilation) 5. Fear of one’s own aggressive impulses Need for intimacy (“libidinal forces”) Fear of intimacy (“aggressive forces”) 1.Physical 2.Material 3.Psychological 4.Significant others Rewriting Negative Scripts Choosing Path of Stress Hardy or Stressed Out Empathy Effective Communication Acceptance of Self/Others Connections and Compassion Dealing Effectively with Mistakes Building Islands of Competence Developing Self Discipline & Self Control Maintaining a Resilient Lifestyle (Brooks & Goldstein . The Power of Resilience). Trauma’s Impact on Self View Identity Body image and sensations Internalized image of others Values Sense of purpose and meaning See self as damaged goods, worthless, evil Fragmented, compartmentalized Feelings of guilt and shame Negative perception of self in relation to others Schemas: 1. Beliefs and expectations about yourself, others, and your world. 2. Guide and organize how to process information and how to understand life’s experience 3. Become basic rules of life [Williams & Poijula (2012). The PTSD Workbook] Compulsions Compulsive Behavior 1. Comes from an identifiable source 2. Operates in a predictable pattern 3. Can be alleviated through a process of awareness, clarification and recovery “Compulsions serve as clues to the deeper stories of our lives, an individual’s history of emotional woundedness.” A compulsion covers up an interior emptiness. It indicates the presence of a control mechanism – a way of escaping something that is ultimately unescapable and unavoidable. Compulsions represent attempts to compensate for low self esteem and powerlessness. The immediate agenda of a compulsion is to maintain a sense of basic survival in the face of what feels like certain annihilation. The frequency of repetition depends on the depth of one’s pain and/or current difficulties in life. Engaging in compulsive activity creates the illusion of control. Pursuing the illusions creates betrayal. [Larkin & Whiting (1991)] Dissociation Derealization = “this isn’t actually happening” Depersonalization = “it isn’t happening to me” Amnesia = “it never happened to me” Multiple personality = “it happened to somebody else” Other constellation of symptoms: Spacing out = cognitive disengagement Out of body experiences = physical disengagement Analgesia = affective or sensory disengagement Challenges to Address Anger The key to transforming anger is self awareness. 1. Spot the unrealistic expectations you have for yourself, other people and things, that, when unmet, trigger anger. 2. Dampen rising anger before it becomes too intense to control. Learn the physiology of anger; how your body reacts and how you can learn to read physical changes so you can exert control. 3. Identify how thoughts can direct you toward or away from an unwanted face of anger. 4. Communicate thoughts and feeling using “assertive problem solving.” [Nay (2012). Taking Charge of Anger: 6 Steps to Asserting Yourself Without Losing Control] 4 “P’s” of Anger 1. Your anger has a PAST – when you learned hurtful ways of dealing with angry feelings. 2. Your anger has a PURPOSE – what you use anger for. 3. Your anger has a PATTERN – what you think, feel, and do over and over in response to the same kinds of situations. 4. Your anger has a PAYOFF – what you get by being angry and acting it out. [Culler & Freeman-Longo. (1995). Men & Anger] Techniques List reasons to identify feelings. List ways to have expressed feelings. Keep feeling journal (log). Do feeling lifeline. Identify blocks to feelings. Identify stuffed feelings. List positive and negative effects of feelings. Situation Perception Training (triggers, thoughts, feelings, action). Distinguish between healing reaction and feeling response. [Cullen & Freeman-Longo (1995). Men & Anger] Healing Interventions Increasing Affective Expression: Gestalt Empty Chair Psychodrama Letter Writing Art Work (collage) Anger List Role Play Breathing Techniques Bioenergetic Release Debrief Affective Experiences [Crowder (1995). Opening the Door.] Healing Interventions Visualization: Identify “anchors” for adult self Inner Self Visualization Container Visualization Safe Place Resource Visualization [Crowder (1995). Opening the Door.] Boundaries Healthy physical and emotional distance between yourself and others. Relationship limits. Define where you end and where someone else begins. Help recognize what is and what is not your responsibility in relationships. Let people in and keep people out. Protect your thoughts, feelings, body, and behavior. Help tell what’s right and what’s wrong. Help you gain respect and show respect for others. External Boundaries – protect your body physically and sexually, keeping it safe and healthy. Internal Boundaries – protect your thoughts and emotions, protecting feelings and spirituality. [McGee & Buddenberg (2003). Unmasking Sexual Con Games.] Faces of Anger Passive Aggression Sarcasm Cold Anger Hostility Aggression [Nay (2012). Taking Charge of Anger] Anger Log Triggers > expectations Thoughts > self talk Feelings > emotions Actions > response choices Outcomes > personal impact/external impact [Nay (2012). Taking Charge of Anger] Anger Intensifiers Sleep Stress Substances Sustenance Sickness [Nay (2012). Taking Charge of Anger] Personal Anger Scale Examine the prelude to your anger in closer detail in order to construct an anger scale that reflects your personal pattern of anger arousal. Note the sequence of body changes as anger escalates, it always includes symptoms of “fight – or – flight” anger arousal. Describe the physical sensations experienced at each significant increment in anger. Link “desired behaviors” at each numbered stage that would be initiated when anger reached that point in the future. [Nay (2012). Taking Charge of Anger] Personal Anger Scale Ratings Physical Sensations Desired Behaviors 0 – 20 relaxed awareness 21 – 40 tension manage tension, sit down, relaxation breathing 41 – 60 rapid breathing 3 anger management tools hit 50 = leave situation 61 – 80 standing up, pacing, “time out” = return to 40 or clinched fists below 81 – 100 chest pounding should be gone [Nay (2012). Taking Charge of Anger] Steps of Anger Management 1. Understanding and Recognizing Anger 2. Identifying and Preparing for Anger Triggers 3. Tracking Anger Body Sensations and Dampening Arousal 4. Identifying and Challenging Thoughts That Fuel Anger 5. Using Assertive Problem Solving 6. Sustaining New Behavior and Coping with Roadblocks [Nay (2012). Taking Charge of Anger] The “STOP” Model for Anger Management Stop > visualize stop sign, breathe, time out Think > self talk > challenge negative thoughts Objectify > think of facts Plan > problem solve [Nay (2012). Taking Charge of Anger] Four Main Styles of Rage Intimidator Interrogator Distancer Poor-Me [Lee, J. (2006). The Missing Peace: Solving the Anger Problem for Alcoholics, Addicts and Those Who Love Them] Unhealthy Ways Anger Is Expressed Manipulation Control Sabotage Jokes Shaming Blaming Demeaning Demoralizing Criticizing Preaching Teaching Judging Analyzing Rigidity Verbal Threats Word Games All or Nothing Attitude / Black & White Thinking [Lee, J. (2006). The Missing Peace] Basics of Mind-Body Nurturing 1. Nurture the Body: relaxation approaches = meditation, guided imagery, progressive muscle relaxation. 2. Nurture the Mind: cognitive restructuring, truth seeking analysis, evidence based thinking, affirmations. 3. Nurture the Emotions: practices of emotional awareness, expression and communication, emotional regulation, journal writing. 4. Nurture the Self/Spirit: - making commitments to various aspects of self (ex. creative self or sexual self) - realize and enact kindness toward the self. - cultivate control, self confidence and inner peace through imagery exercises, affirmations, self styled prayer said inwardly. [Domar & Dreher (2000). Self Nurture] Self Nurture & Anger: A Healing Connection Healthy expression of anger is synonymous with assertiveness. Self nurturing requires strong statements about limits, boundaries and needs. Suppressed anger or “amicable repressors” can produce a variety of ill effects. Anger is necessary in our emotional repertoire to defend and assert ourselves. At the other extreme, “compulsive expressers” vent fury at the slightest provocation. Anger is an alarm bell, a signal that something is wrong and needs to be addressed. Identify models for your own emotional expression. STOP/BREATHE/REFLCT/CHOOSE guidelines enable you to consider the most effective, assertive words and actions. [Domar & Dreher (2000). Self Nurture] Communication Skill Quadrant Assertive Aggressive I count I count You count You don’t count Passive Aggressive Passive I count I don’t count You don’t count, but I’m not going to tell you You count [Domar & Dreher (2000). Self Nurture] Eight Methods of Relaxation Simple guidelines for any method for eliciting the relaxation response. Find a quiet place Choose regular time of day; sense of ritual keeps commitment strong; protect your relaxation time. No set time, most take 15 – 25 minutes. Be flexible to mix, match and change methods. 1. Breath Focus: Shift from shallow chest5 breathing to deep abdominal breathing. 2. Body Scan: Identify body parts; breathe in and notice tension, breathe out and release tension. 3. PMR: - Mental focus and breathing - Increase body tension before releasing. [Domar & Dreher (2000). Self Nurture] Eight Methods of Relaxation 4. Meditation: Turning attention inward, repetitive focus on breathing and a simple word, phrase or prayer. 5. Mindfulness: - Nourishing capacity to be in the present which engenders gratitude for the wonders we experience through our senses, emotions and intellect. - Mindful walk, mindful meditation, mindful activity 6. Guided Imagery: Visual imagery is a phenomena of mind and body, imagery can have physiologic consequences. 7. Autogenic Training: A form of self hypnosis using verbal suggestions, which amounts to a form of progressive relaxation for the body. 8. Yoga: A blend of physical postures, meditation and deep breathing. [Domar & Dreher (2000). Self Nurture] Mini Relaxations Portable stress managers, calm down and reclaim your center Short form versions of the breath-focus meditation Uses deep abdominal (diaphragmatic) breathing Version l • Secure a comfortable position • Take deep slow breath • Place hand on abdomen, allow abdomen to rise as you inhale • As you exhale, notice your abdomen fall; also notice your chest rises and falls as does your abdomen. [Domar & Dreher (2000). Self Nurture] Mini Relaxations Version 2 • Use deep abdominal breathing • Count down from ten to zero, taking one complete breath (one inhalation, one exhalation) with each number Version 3 • Use deep abdominal breathing • As you inhale, count from 1 to 4. As you exhale, count back down from 4 to 1. Version 4 • Use deep abdominal breathing • Add a ten to zero count with each breath, or add a 1 to 4/ 4 to 1 count as you inhale and exhale. • Pause for a few seconds after each in-breath and pause again for a few seconds after each out-breath. [Domar & Dreher (2000). Self Nurture] Cognitive Restructuring: The Mind Nurture Method Listen to the voices in your head. Record the messages that you hear. Note the positive messages and reinforce them. Note the harsh, critical inner voice with the negative tape loop – a repetitive, nagging monologue of fearful or self denigrating comments about ourselves, our bodies, our abilities, life and prospects for happiness. Note the “greatest hits” – specific tracks of negative self talk that replay repetitively at the slightest provocation or no provocation at all. [Domar & Dreher (2000). Self Nurture] Cognitive Restructuring: The Mind Nurture Method Self punishing thought patterns represent the foundation for low self esteem and are the mental fuel for anxiety and depression. Defuse the punishing mind with a balanced, thoughtful, self caring series of questions. Cognitive restructuring bolsters self esteem by building realistic compassion for ourselves and others. Use evidenced based thinking. Replace the negative thought with a kinder, more realistic assessment. Endless unchallenged negative thinking can lead to self sabotage or self fulfilling prophecy. [Domar & Dreher (2000). Self Nurture] Nearly everyone has negative internal self talk. Some have the internal chatter going on almost all of the time. [Andreas, Steve (2012). Transforming Negative Self Talk] Internal Voices May remind us of past failures, sorrows or disappointments Torture us with criticism or verbal abuse Describe frightening or unpleasant future Can cause unpleasant feelings which may interfere with reaching goals and achieving success Can result in depression, anxiety or panic attacks, violence or paranoia Can be transformed [Andreas, Steve (2012). Transforming Negative Self Talk] Cognitive Process in Targeting Dysfunctional Thoughts (1) Identify the Situation (2) Identify the Feelings (3) Identify the Underlying Thoughts (4) Evaluate the Thought (5) Take Action [Mueser, Rosenberg, & Rosenberg (2009). Treatment of PTSD in Special Populations] Format for Challenging Self Limiting Beliefs Where did the belief originate? How does the belief impact/affect life now? What situations provoke this belief? What are negative consequences to the belief? What are the positive consequence of continuing this belief? (What am I getting? What am I avoiding?) [Dr. Jordan & Margaret Paul (1989). From Conflict to Caring] Emotional Expression: Keeping a Journal Nurturing emotions should be an integral component of broader efforts to self nurture. Much of stress originates from within, when anger or grief control our lives. The answer is not to talk ourselves out of negative feelings, suppress them, or even to discharge them in explosive efforts to ventilate. Accept full range of emotions and stop labeling them negative. [Domar & Dreher (2000). Self Nurture] Affirmations & Prayer: Spirit Nurture Affirmations can cultivate control, self confidence and peace. Incorporate affirmations into daily relaxation rituals. During meditation, you can incorporate affirmations in rhythmic concert with breathing (ex. “Still, Here”) Prayer can aid physical and psychological healing. Self nurturing spirituality = framework of self love that can help to achieve tranquility, acceptance and wisdom. Practice prayer as you would meditation. Choose a focus word or phrase that has spiritual meaning for you. (Exs. Christian: Jesus, Mary, Joseph, God; Jewish: Shalom; Islamic: Allah) [Domar & Dreher (2000). Self Nurture] Behavioral Addictions Core qualities of many impulse control disorders: 1. Repetitive or compulsive engagement in a behavior despite adverse consequences. 2. Diminished control over the problematic behavior. 3. An appetitive urge or craving state prior to engagement in the problematic behavior. 4. A hedonic quality during the performance of the problematic behavior. [Grant (2008). Impulse Control Disorders.] Commitment to the 4 “C’s” of Treatment 1.CHALLENGE old thoughts 2.COPE with strong feelings 3.CHANGE your environment 4.CREATE a balanced life Avoidance Strategies – avoid the situation altogether; keep the situation from occurring; the best-case preventive strategy in the case of an impending high risk situation. Control Strategies – for use after already in a high risk situation; reminding yourself of consequences, use decision matrix card; generate alternative coping options. Escape Strategies – leave the situation; generate realistic options to remove you from the high risk situation. [Sbraga & O’Donohue (2005). The Sex Addiction Workbook] Impact of Trauma on Interpersonal Relationships Feelings of alienation from others in social, emotional and personal areas of life Mistrust and guardedness Detachment, isolation and withdrawal Loss of pleasure in life and the capacity for joy Loss of ability to feel sensual and sexual or have sexual feelings Loss of capacity to experience healthy connectedness to others Repetitive self destructive relationships Discontent with self-comfort and an inability to receive nurturing (even touch) from others and self Problems with boundary setting and maintenance Problems communicating wants, needs and emotions Feelings of abandonment and loss that may or may not be based on fact [Williams & Poijula (2012). The PTSD Workbook] hysical ecreational esthetic ntellectual piritual motional exual INTIMACY: -Personal identity testing & consolidation -Unfinished business resolution -Ability to form mature intimate relationships: give and receive -1 + you = WE 1 + 1 = 3 “Synergism” -Interpersonal effectiveness expansion -Increase self confidence -Ability to honor commitments -Focus on special interests -Balanced living -Dreams/life plans/productivity -Setting priorities with action plan -New family identification -PRAISES model for intimacy [Adapted from Erickson in Corey (1990). Theory & Practice of Group Counseling] AUTOMATIC TRIGGERS THOUGHTS CHALLENGES RELAPSE EMOTIONS BEHAVIOR REINFORCERS NEGATIVE CONSEQUENCES ACR’S My Relapse Behaviors Are: 1. List emotional and interpersonal triggers. 2. Describe some apparently irrelevant decisions made in the past. 3. Identify high-risk situations. 4. Identify lapses you have experienced in the past. 5. Specify non-addictive coping resources you will use. 6. Write names and telephone numbers of people you will call for support. 7. Record plans for modifying work life for better balance. 8. Record plans for modifying leisure life for better balance. 9. Record plans for modifying social life for better balance. 10. Record plans for modifying spiritual life for better balance. 11. List tentative plans for aftercare for the first 90 days. 12. State your healthy sexual boundaries. 13. State your healthy relationship boundaries. 14. List accomplishments: five past, five made in treatment, and five future realistic goals.