Sallie Foley, Trauma and Trauma treatment, 2009 1

Trauma Course

I. Introduction A. Overview of materials for course—syl and bib B. Overview of course expectations C. Overview of lectures D. Confidentiality, difficulty of material reviewed, need for taking responsibility for self in handling this difficult material E. The goal: to develop the ability to self-regulate and self-soothe; to develop safety in treatment so that the person can develop a coherent narrative of what happened to them, grieve, adjust their framework of a ‘just world’ and move on to live a meaningful and related life. F. Many ways that trauma can affect people: accidents, child abuse neglect (12/1000/year), violence, bites from animals, domestic violence, hostage, medical illness, homicide, suicide, natural disasters, death of loved ones, school violence, sexual abuse, rape, terrorism, war, car accidents (children: most common form of unintentional injury—1500 deaths/125,000 injuries/year) II. Attachment, indivduation, regulating anxiety, defense mechanisms

• And early use of imaging/transitional objects/introjects to regulate fear/anxiety—peekaboo. • Mediating variables in development of PTSD • The Corpus Callosum Area and childhood neglect (Teicher, et al, Biological Psychiatry, 2004:56:80-85)

III. History of trauma in general population A. Former descriptions B. Situations of trauma across cultures and development—attachment disruptions, war, illness, surgeries, cultural genocide, rape, abuse C. Definitions of trauma by DSM IV-TR i. Acute stress disorder ii. PTSD iii. Complex PTSD—symptoms of severe PTSD mimic severe mental illness, but are not. It is fixable, never give up. iv. DESNOS v. Other—differential diagnoses/ADHD, Grief reactions D. Common forms of cultural treatment of trauma historically E. Past ways of treating trauma in last 25 years: the ‘scrape it out’ implosion problem F. New: we are now clueful, We know symptoms mimic severe mental illness but aren’t. It is essentially a biophysical condition, We now know that talking about it is not necessarily the place to go first, especially about painful and recent events, We were taught to cut through the pain to the most upsetting things. Sallie Foley, Trauma and Trauma treatment, 2009 2

G. What is wrong: with PTSD, you establish safety first, not talk. Instead: ask How are you doing, what are your symptoms like? Do not start with: “Tell me what happened,” i.e. 9/11, First responders would say this and it’s wrong place to start. i.e. CISD: used to do this, but go to social circumstances and build in social support. Try to handle the flooding. H. Judith Herman and three phase understanding of trauma treatment: Safety, Recollection and Mourning, Reconnection I. Emphasis on self-regulation and self-soothing, safety J. Problem of kindling K. Recent developments from epidemiology, clinical studies, and biochemistry that are impacting how we think about trauma L. Types of trauma research: Terr on Type I and Type II. Finklehor on betrayal in attachment and not being able to develop enough language or anger to feel separate from perpetrator. Mary Main on individuation. M. Marsh Linehan, Univ. of Washington/Seattle. Dialectical Behavioral Therapy. Mindfulness techniques taught. Teach clients to understand that helplessness drives ‘either-or’ thinking, black/white thinking. When one feels helpless, the move it to move to rigidity because of the fear of chaos. Teaching clients to ‘notice’ their judgment, notice their racing thoughts, notice their either/or thinking, rather than moving into those states. Try exercise with grapes.

IV. Trauma and children: earlier it was believed that children didn’t understand and had mild reactions, that interventions weren’t necessary because the reactions were transient. V. Video with Bessel van der Kolk VI. Trauma reactions (thanks to D. Fischer) children all: sleeping difficulties, - infants: feeding/weight gain problems, increased crying, clingy, delays in attaining developmental milestones - toddlers: withdrawn, anxious, clingy, loss of language/babbling, night- mares, play re-enactment, behavior regression - school age: behavioral changes, loss of predictable patterns of reaction interaction, school performance changes, negative behaviors increase, increase in somatic behaviors - adolescents: increase irritability with friends, absenteeism, substance abuse, high risk behaviors , decreased impulse control, over involvement in discussions about trauma - symptoms can be partial, are often overlooked, are distressing, not all children exposed to trauma develop PTSD - disregulation of fight/flight (increased agitation or dissociation), trauma re-enactment, irritability, sleep problems, eating problems, behavioral problems, substance use - Lifetime prevalence: 1-14%.

Sallie Foley, Trauma and Trauma treatment, 2009 3

VII. Trauma and the Brain A. Neurobiology and the body 1. The up/down brain of humans—getting the terms straight (handout) 2. How is stored 3. The arousal system in the brain-the amygdala is not mediated by the frontal cortex. Threat: The messages to the body. The release of stress chemicals especially cortisol and epi/norepi. It is immediate. It increases alertness, dilating pupils, muscle tension to limbs, focus, short term memory, ocular divergence (seeing out the sides/peripheral vision). This jolt could be sexual arousal, something joyful, an amusement park ride, a danger. The amygdala has to sort it out. 4. The analysis of the threat—comparisons with past threats, and checking out the assessment to see if this is a genuine threat or the appearance of one. If genuine, then stress hormones shut down any function that is not necessary. Anything superfluous to survival, like digestion, sexual function Everything that happens next in the body is about fight or flight. Increased blood pressure, heart rate 5. Endogenous opiods. Your complete internal pharmacy. This is like ‘superpainkiller’ and never lets the person be distracted by the pain. Explain the brain to your colleague. B. Siegal, Scaer, Peter Levine, Bessel van der Kolk C. Fight Flight and Freeze. Peter Levine: Trauma is a fundamentally a highly activated incomplete psycho-physiological response to threat, frozen in time. What is significant in the resolution of trauma is the completion of incompleted responses to threat and the ensuing discharge of the that was mobilized for survival.” D. Stress: body’s reaction to demand placed on us. How the body reacts to challenge or threat Stress reaction: physiologically—activation of the autonomic nervouse system (ANS), release of certain hormones into the blood Traumatic stress: state when facing an extreme threat and there is an extreme activation of the ANS. Triggers a survival reflex: flight/flight/freeze to overwhelming situations where we see our life or the lives of others close to us at risk and actual survival appears threatened Traumatic stress creates disruption in normal brain functioning, whereas normal stress does not Normal stress improves problem solving and productivity Genetically programmed reflex activates life-preserving survival response in body/nervous system Freeze: If trapped, freeze response. Assumes a state of immobility manifesting high activation of nervous system; humans often do not move through flight/fight/freeze response. Frozen state of hyperarousal in limbic Sallie Foley, Trauma and Trauma treatment, 2009 4

and implicit (procedural) memory systems may persist. In this state, a person struggles to modulate the arousal response. The highly aroused state of fight or flight is designed to enable short-term defensive actions. If this energy isn’t used by completing the defense actions, the activation is held in the nervous system and is unable to dissipate or release (immobility/freezing response). When energy doesn’t get to ‘complete’ what happens. Even though immobilized, nervous system highly aroused. Not able to discharge any for the fight or flight energy, animals using freezing response allow for biological discharge of excess energy and completion of the arousal cycle. They do this through shaking and trembling and this restores spontaneous breathing and the nervous system to regain balance. Humans too frightened and uncomfortable with surrendering to involuntary sensations and discharge so nervous system remains in state of arousal. A state of continued autonomic hyperarousal remains. But the frozen rezones seek completion and energy exert strong pressure on the organism to resolve. Thins gives rise to many of the symptoms associated with trauma, including dissociation. The frozen state of autonomic hyperarousal or inadequate discharge of energy – excess energy which becomes bound in the person’s mind and body and symptoms of trauma are the result. This arousal or activation is the energy needed to work in healing to trauma. Must teach people to modulate this arousal while working to release frozen activation and impulses bound in the body. E. Dissociation and altered states as hardwired F. Belleruth Naperstek—believes that imaging relies on primitive brain processes. It is the land of emotion and perception and feeling and sensory images. The land of kinesthetic sensation, symbol, metaphor, and muscular activity. The land of imagery is this land and it is the same land that gets activated when we are threatened. G. Imagery is a best practice because it can go exactly where trauma sits in the brain. It goes in the back door. Imagery is a way of working with healing while minimizing distress. It isn’t just visualization. Only 55% of population is visually wired, so must use other sensory modalities. Imagery that is body based, kinesthetic is the most healing. It is immersive, multisensory, done in altered state, body based, and deliberately evocative of emotion.

VIII. Why talk only doesn’t work. A. Kindling B. Doesn’t get to the amygdala and help develop new pathways C. Imaging: using altered states to fight altered states—Practice explaining this to your colleague. IX. The range of therapies A. Types of therapy: psychodynamic, attachment therapies, CBT, Alphabet therapies, psychoeducational models, biological, group, body work- Sallie Foley, Trauma and Trauma treatment, 2009 5

massage therapies, , DBT models, movement—tai chi/yoga/walking, integrated models, family models, rituals/memorials/cultural statements (Truth and Reconciliation, spontaneous memorials, Kosovo circles in the square, Holocaust memorial) B. Assuring safety first. Use models that provide self-regulation and getting back in the body X. Early techniques for providing safety A. Early responding/crisis intervention 1. Breathing—called ‘Targeted Breathing’: immediately after terrifying event: finding a place inside your belly and breathing into it. Counting to three and breathing out and counting to three and breathing in. (this was used as best technique at ground zero) Can shift biochemistry quickly and can be repeated as necessary. Results last usually 45 min-2 hours. Practice breathing; teach breathing 2. Kids are more amenable. Very helpful to children. Use fewer words. 3. Most important things are voice and music with all lower brain functions…the survivor functions. They respond to the ‘flavor of safety.’ 4. Installations using bicameral movement with CBT— consider butterfly hug B. Boundaries and clarity C. Setting limits and clear expectations D. Early PTSD tx: right after trauma all they want is to self-regulate and get emotion under control. To reduce flooding, build safety. Here if you use imagery, make it simple not emotive

XI. Introduce an imaging exercise: Belleruth Naperstek A. Guided neutral: image for phase 1 after trauma. B. Neutral, begins with breathing and then parts of body, then heart beating. C. Note that we move in this exercise to a second that was more evocative. This part would be better for later, after getting flooding taken care of. D. Music should be soothing, repetitive, and necessary E. You can ask a client, what music suits you best? You can send them to healthjourneys website. F. 85% of those traumatized will be comfortable with going with imagery exercises. G. Remember that these clients are champs at the altered states. Imagery is a targeted altered state. Let people customize this. i.e. stand, pick own music, titrate dosage, listen to tapes as they can tolerate.

Sallie Foley, Trauma and Trauma treatment, 2009 6

XII. The use of medications A. First line of treatment: SSRIs B. Know good psychiatrist C. Remember that symptoms can mimic severe mental illness

XIII. Mourning and recollection therapies—the middle Remember: real treatment cannot begin until the person is safe and the trauma/abuse has stopped A. Emphasize easy access to first line of treatments, getting back to grounded as needed B. Maintain self-regulation C. Continue Psychoeducation about how trauma works and need for safety and development of new neural connections to shift D. Provide predictability about what you will do next. E. Don’t be afraid of trying new things as you learn them, just make sure you have the client agreement and understanding and watch your pace/speed (your enthusiasm may cause you to move too fast) F. Address in an ongoing manner, any behaviors or thoughts that are disruptive and disregulating for the person. Even as you do grief work, you are continuing to work on ‘Task 3: What is your life like now? How are you adjusting in a healthy manner?’

XIV. The Cognitive Behavioral Therapies A. Use of exposure and titration of experience B. Managing flooding and kindling

XV. Body work A. Memory stored in sensorimotor systems and body movements can trigger flashbacks. Use competent people. B. The freeze reaction doesn’t get ‘shaken out’ as it does in other animals and stores as extra chemical load in the body. C. Acupuncture D. Body massage E. F. Craniofacial massage G. Exercise H. Walking

XVI. Imagery A. Imagery uses archetypal themes, universal elements, is intuitively ‘corny’ or ‘sentimental,’ as if you are getting the whole human race behind the intention to heal. Remember Jung’s collective unconscious: 3 elements for healing: sacred space, magician energy (God), and ritual of undoing and reconstituting. Imagery can sometimes be experienced as profound or Sallie Foley, Trauma and Trauma treatment, 2009 7

mystical experience. Remember that trauma survivors need a big place ot hold all that pain. B. Music: let music lead the imagery, use space for images to come up. C. Imagery studies: indicate increase in cognitive function. The Duke/Durham VA Hospital experiments: military sexual trauma. Terrorized female soldiers who were raped multiple times by their CO’s and then had to still work with them. 12 week long study. 1. neutral imagery first 2. then trauma imagery 3. each vet got their own mp3 player recording device and it recorded how many times they listened to the imagery. Measurements were: BECK (a standard measure for depression) plus measures of PTSD including the CAPS (The Clinician Administered PTSD Scale), PCL (PTSD Check List). 4. The controls just got to listen to the music, no imagery. 5. Findings: Significant reduction on the CAPS, PCL, little better than best CBT. 6. The clusters they were looking at were: arousal, avoiding numbing, re-experiencing and flashbacks. 7. CBT has had best impact always on arousal and avoiding/numbing but hasn’t been able to help with re- experiencing and flashbacks 8. In this study the imagery was slightly better than CBT on arousal and avoiding/numbing reduction 9. But it was best on reducing re-experiencing and flashbacks 10. Re-experiencing was most reduced, then arousal reduced at same rate as CBT prolonged exposure. 11. They are now repeating this in a larger study. They will track complicated neurobiological markers including complicated neurosteroid markers in the blood and will conduct cognitive MRIs over time to see if guided imagery has sustained results.

XVII. Why use evidence based treatments? A. All system wide adoption of technique requires techniques that are empirically tested. You must have research. B. Clinics, shelters, VA hospitals, the military do care about treatment but must be cost effective based on knowing something works C. I.e. VA vets getting imagery as a download. D. “give an hour” a therapist registers on line to help vets E. Van der Kolk—studying Yoga with returning vets F. Fort Carson—before deployment people are trained in yoga, acupuncture, and guided imagery. Need things that are quick, portable, and self administered Sallie Foley, Trauma and Trauma treatment, 2009 8

G. When working with all first responders or the military, must change your language. Not therapy nor medical model oriented. Instead: Learning module, new skill set, educational, self-mastery training You have to understand the culture you are connecting with. I.e. Google Magi’s group—an ex-marine using educational language and the ‘warrior optimication systems”, war-ops, famops H. If you don’t adapt the language, you will lose the person I. Military is very interested in pre and post deployment using yoga, tai, chi, guided imagery and massage therapy

790 Part 2 Trauma Course RECAP OF SOME BEFORE AS WELL AS MORE DETAILED TREATMENT INFORMATION

XVIII. Other Mindfulness exercises. Repeat: Herman model: Safety, Recollection and Mourning, Reconnection

XIX. Attachment, individuation, regulating anxiety, defense mechanisms

And early use of imaging/transitional objects/introjects to regulate fear/anxiety. Read Viktor Frankl

Imagery as transitional object: It’s always there. It encourages control. It’s internalized.

Play second Imaging tape/Naperstek

XX. The range of therapies A. Types of therapy: psychodynamic, attachment therapies, CBT, Alphabet therapies, psychoeducational models, biological, group, body work- massage therapies, acupuncture, DBT models, movement—tai chi/yoga/walking, integrated models, family models, rituals/memorials/cultural statements (Truth and Reconciliation, spontaneous memorials, Kosovo circles in the square, Holocaust memorial)

IV. Early techniques for providing safety A. Early responding/crisis intervention 1. Breathing—called Targeted breathing: immediately after terrifying event: finding a place inside your belly and breathing into it. Counting to three and breathing out and counting to three and breathing in. (this was used as best technique at ground zero) Can shift biochemistry quickly and can be repeated as necessary. Results last usually 45 min-2 hours. Sallie Foley, Trauma and Trauma treatment, 2009 9

2. Kids are more amenable. Very helpful to children. Use fewer words. 3. Most important things are voice and music with all lower brain functions…the survivor functions. They respond to the ‘flavor of safety.’ 4. Installations using bicameral movement with CBT: Give a statement: I.e. Although I was scared, I am safe now. B. Boundaries and clarity C. Setting limits and clear expectations, especially for how to follow up for more treatment D. Early PTSD tx: right after trauma all they want is to self-regulate and get emotion under control. To reduce flooding, build safety. Here if you use imagery, make it simple not emotive

V. The use of medications—Many experts insist that the early use of SSRI/SNRI is important in settling the brain’s neurophysiological functioning

a. First line of treatment: SSRIs/SNRIs b. Know good psychiatrist c. Remember that symptoms can mimic severe mental illness

VI. Psychotherapy Mourning and recollection therapies—the heart of treatment a. Continue to emphasize easy access to first line of treatments, getting back to grounded safety as needed b. Maintain self-regulation throughout treatment c. Continue Psychoeducation about how trauma works and need for safety and development of new neural connections to , throughout treatment d. Provide predictability about what you will do next. e. Remember that you are continuing to work on all aspects of self- regulation, including faulty thinking/poor relationship choices/disregulation f. Don’t be afraid of trying new things as you learn them, just make sure you have the client agreement and understanding and watch your pace/speed (your enthusiasm may cause you to move too fast)

VII. The Cognitive Behavioral Therapies a. Use of exposure and titration of experience to reduce symptoms of arousal and numbing b. Goal of managing flooding and kindling c. Follow established protocols. Consider Foa, Linehan, Horowitz d. Usually follow established method of gaining agreement for treatment, identifying and targeting behaviors wish to change, identifying negative thoughts and behaviors, identifying positive changes that are goals, keeping goals realizable. Sallie Foley, Trauma and Trauma treatment, 2009 10

e. Maintaining calm supportive protocol of both thoughts and behaviors toward goal change. Often involves the telling of the story of the trauma and the use of exposure to the upsetting event. Often addresses behaviors that are ‘avoidant’ and careful restructuring. f. It helps if the person does not think they are ‘reliving it’ but instead are telling it as if it is happening on a TV screen in front of them that they can stop and start. It also relies on trusted other person so that sense of aloneness/isolation is reduced. Safety must be present. g. Problem: If person gets so triggered by the brain kindling that the person cannot engage in telling the story of the event. Or: if the person cannot recall in words the trauma narrative. h. Prolonged exposure and re-experiencing creates distress that the person learns to tolerate. Foa uses it with only military sexual trauma and rape victims, but does not use it with people who are soldiers (i.e. people who perpetrated ‘trauma’ on another).

VIII. Body work a. Memory stored in sensorimotor systems and body movements can trigger flashbacks. Use competent professionals within the bodywork community. b. The freeze reaction doesn’t get ‘shaken out’ as it does in other animals and stores as extra chemical load in the body (see work of Peter Levine, Robert Scaer). c. Acupuncture d. Body massage e. Reiki—the transferring and directing ‘life force energy’ to another person through hands on or just over the body. A form of body work. Not a substitute for standard medical care. Requires formal teaching. f. Craniofacial massage—focuses on head and neck g. Exercise h. Tai Chi, Yoga i. Walking

IX. Imagery a. Imagery uses archetypal themes, universal elements, is intuitively ‘corny’ or ‘sentimental,’ as if you are getting the whole human race behind the intention to heal. Remember Jung’s collective unconscious: 3 elements for healing: sacred space, magician energy (God), and ritual of undoing and reconstituting. Imagery can sometimes be experienced as profound or mystical experience. Remember that trauma survivors need a big place to hold all that pain. b. See Naperstek, Healthjourneys.com as good example. These are guided imagery ‘journeys’ and direct the person to address aspects of trauma/loss. c. Use of dissociative state to alter dissociative state.

X. Psychotherapy Sallie Foley, Trauma and Trauma treatment, 2009 11

a. Movement away from single session or short session PTSD psychotherapy. Now there is more of an acknowledgement that in short time safety, psychoeducation, self-regulation and self-soothing should be taught. b. Longerterm psychotherapy. Remember: the greatest emotional component of PTSD is grief. Tremendous loss issues. Must be grieved. Sallie’s discussion of two cases. c. Read Herman for excellent discussion of psychotherapy. Also Healing Trauma book and Rothschild book. d. To learn psychotherapy, read psychotherapy: Martha Stark, Eda Goldstein, Irving Yalom, Mary Pipher

XI. Alphabet therapies—almost all these protocols will be similar. There will be a 5 minutes of doing something immersive, then re-experiencing, then new assertion, then 5 min. of ‘sealing it’ with immersive state. You are actually eliciting a parasympathetic response (nervous system is calmed down) and so the person is able to lessen their own responses over time. In this way, it is like a neurophysiologically driven CBT. All same at their core: imagery. This allows the client to calm their systems on this parasympathetic level.

All techniques tend to start with ‘where the client is’ and with the upsetting image the client presents. The image often changes during treatment, often the images shift and become more upsetting as the client moves ‘through’ the treatment. a. Imagery rehearsal therapy: IRT. Lessens nightmares. Person writes out their dream/nightmare. Ask: What does this dream tell you/mean about you?. ….I.e. Answer might be “I’m bad. I don’t deserve to live.’ Then therapist asks ‘countervailing positive assumption that the person would like to have. I.e. “I’ve done some good things. I did a good thing that day.” Then therapist says What could you tack on as an ending to this dream that can allow you to wake up in a peaceful state?. Then the person listens to 5 minutes of guided imagery or peaceful music or something soothing, followed by re-imagining the dream with the tacked on new ending and the positive assumption that they say to themselves. Then 5 minutes more of music. b. EMDR—Eye movement desensitization reprocessing. Requires very strict training and should never be attempted without the specific training in this. This is the most studied one against prolonged exposure (CBT) techniques. -First image of safe and peaceful place. Make access to image multisensory, i.e. oasis imagery. This is then used in case a person feels flooded or overwhelmed. -Next, what was the most vivid image that was upsetting. i.e. 911: the plane into the building -What was the negative thought : I am helpless -Rate the image on a SUDS scale (1-10) Sallie Foley, Trauma and Trauma treatment, 2009 12

-Rate the physical sensation (gut awful feeling) SUDS scale -Rate the negative belief, 1-10. -What is the positive belief you want to have. I can help people today. -Rate the positive belief 1-10 Then do bilateral crossing midline treatment (tapping, eye movement, sound, etc) -Then rerate, reduces SUDS. Install positive belief. c. Thought field imagery TFT- Roger Callahan creator, Variation of EMDR. Expensive to train. Has many algorithms for tapping on different parts of body, meridians, then muscle testing with acupoints. Clinicians found that the algorithms weren’t necessary. c. Emotional Freedom therapy (emofree.com). Good! Gary Craig posts it on His website. Very creative site. Engenders less distress than EMDR, less flooding. He has added tapping and saying an affirmation (i.e. Even though I am afraid of snakes, I completely and fully accept myself.). You don’t have to be an expert to use it. You can sit with a client and they can use it. d. Wholistic Hybrid of EMDR and EFT (WHEE). Daniel Benor…British Clinician. Often used with children. e. Trauma Incident Reduction, TIR—Gerald French and Frank Gerbode. This is a procedure not a therapy. Has a manual. Very specific. Don’t have to be a therapist because anyone can get this manual from amazon.com. Good results with vets. Uses idea of seeing upsetting image as on a TV/video in front of you. Keep rewinding the tape to just before the upsetting/traumatic incident, but don’t press play. The viewer then ‘presses play’ and watches and listens, but does not report (Reporting is a big part of EMDR). He is then asked to tell what happens in the tape. The listener (not a trained clinician but a support person) listens very carefully but does not interpret. The listener’s job is to be interested, not interesting! Keep doing this until the scene stops changing or adding any additional features. This could take a very long time. Nothing is left to chance. The viewer gets more relieved as ‘watches’ with listener present. Support groups regularly use this, but not therapists because it takes an undetermined amount of time. Good treatment for those without money for treatment. f. Somatic experiencing---Peter Levine’s technique. Must be carefully trained in this Traumatic symptoms come from frozen residue in the body that is trapped in the nervous system and must be discharged. Alternating body , titrated carefully, sensation of trauma with calming oasis imagery. Identify oasis imagery, experience that, practice with that, then deliberately introduce process of ‘pedulation’ or looping (back and forth) from traumatic body memory (NB: a ‘body memory’ is less distressing than the thoughts about the trauma that a person has) to the oasis imagery, then back to body memory. Not mental imagery. i.e. When was the first moment you had a FEELING something was wrong. Can you freeze frame that moment or back up to a safer place and freeze frame that? Now go Sallie Foley, Trauma and Trauma treatment, 2009 13

back as distant as the body wants to, now to the oasis. This technique focuses on strategic use of body memory with the looping. Tries to discharge the energy of the trauma through the unfrozen oasis imagery. Has the advantages of distance, freeze frame, ‘slow motion,’ body based.

An example of an integrated program in the treatment of trauma:

Healing Trauma programs. i.e. Jim Gordon’s Healing the Wounds of War program

Elements: 1. Someone to regularly check in with. Be a ‘witness’ to healing. 2. Support group: commonality n experience is important 3. Assessment for medication 4. Some form of spiritual groundedness. This can be prayer, meditation, ritual that stands for “My intention is to get myself better through this process.” Ritual is a major part of healing for cultural loss. Process of ‘declaring intentions.’ (Think of this more broadly, i.e. weddings, funerals, baptisms, housewarmings, bat mitzvahs, etc.) 5. Simple cognitive information. Given early on and throughout treatment. “This is PTSD. This is what is does to you. You are not crazy.” Etc. 6. Teaching/ helping people to develop self-regulation skills (mindfulness, breathing, tai chi, yoga, meditation) 7. Physical exercise. Move aerobically 8. Body work: doing movement for you on you. Massage, etc. 9. Expressive arts. Often journaling is used. Painting, poetry, etc. 10. Guided imagery: helps in self-regulation and in healing (tx). 11. Alphabet therapies: Safety, working through 12. Griefwork: the biggest emotional component of PTSD is grief over losses (including safety, innocence, just world, etc) 13. Reconnection-establishment of relationships

XII. Groups and the development of art in groups A. Use of ‘grief box’ or ‘grief bag’ B. Use of body mapping/journaling, etc. C. Need for specialized training in groups

XIII. Differential diagnosis and treatment

A. Outline handout Sallie Foley, Trauma and Trauma treatment, 2009 14

B. The case of Jack, how would you treat?

XIII. Practicing imagery exercises from Naperstek.