The Unappreciated Helper

The “Unappreciated Helper”

Traumatized families facing significant daily stress too often find themselves torn apart and living with such conflict and acrimony that their relationships are forever damaged. It is certainly true that living with stress challenges and tests patience, lowers frustration tolerance, leads to ‘frayed nerves,” and irritability. However, those are not always the most toxic components of stress on relationships.

What I am referring to is one of the most frustrating and perhaps paradoxical issues I see occurring in highly stressed, traumatized families. The interaction usually follows something close to this pattern: One family member vents to another his or her feelings of anger, frustration, fear, or some other seemingly unacceptable emotional state over situation ‘X.’ The second family member, usually with the intention of “helping,” gives advice on how to fix or at least change the situation. The two then find themselves in an argument or fight which can leave them both feeling hurt, and sometimes bewildered at what just took place.

What happens is a complex interaction comprising of miscommunication, differing agendas, and an inability to tolerate distress in a loved one. Caring people normally would like to erase the suffering or distress suffered by the people they care about most. However, the person who is venting often is looking primarily only for someone to vent to, not someone to “fix” the problem.

When needing someone to listen but getting “help” instead, it can lead to frustration or feeling invalidated and belittled, as if they could not be expected come up with those ideas on their own. When listening to a loved one in distress, it can lead to frustration when “helpful” suggestions are met with anger and resentment. I often hear the refrain, “Why did you talk to me about it if you didn’t want my help in the first place?” Thus the “unappreciated helper.” Wanting to help is great and doing what we can for loved ones is natural. But knowing when to help, when to listen, and learning to tolerate distress in your loved one while you figure out the difference is key to your success.

Mark E. Hankla

Vicarious Traumatization Workshop March 19, 2014

Sherry Cox will present a one day workshop

Vicarious Traumatization

Preventing, Recognizing & Treating Disorders of Empathy

Wednesday, March 19, 2014 at Southeast Community College

For a brochure please access  https://www.southeast.edu/assets/0/74/87/324/340/672/a315966e-668b-498f-a239-93fbdfe7492a.pdf

Continuing Education for Trauma Therapists

Sherry Cox will present Ethical Guidelines For Trauma Therapists: Helping Without Hurting at Southeast Community College on July 26, 2013.


For further information please visit the Psychotherapy Associates website at: Psychotherapyassoc.com 

To register, contact Nancy Holman, Southeast Community College, 402-437-2712 or 1-800-828-0072, ext. 2712, www. southeast.edu.

Services for Juveniles in Nebraska Changes?

An article in the Lincoln Journal Star on January 24, 2013 caught my eye. The title of the article was “Juvenile justice system overhaul is proposed”. Senators Brad Ashford and Bob Krist of Omaha and Kathy Campbell and Amanda McGill of Lincoln co-sponsored a bill (LB561) which would reorganize the juvenile justice system to focus on mental health treatment instead of punishment. They propose closing the centers at Kearney and Geneva and move to a treatment based system. Senator Ashford reported that 70% of the children in the juvenile justice system have a history of physical abuse and 40% of the girls have a history of sexual abuse. He also states that 70% of the juveniles in the juvenile justice system have a major mental illness which is undiagnosed, untreated or inappropriately treated. Senator Ashford is quoted as saying “Trauma in these children is not systematically screened or treated. We reap what we sow.” He also stated “Children who end up in the juvenile justice system were victims long before they became offenders.”  I think that it is great that the senators have realized that there are youth in Kearney and Geneva who are in need of mental health services. Perhaps if they had received the services they needed, they may not have ended up in the juvenile justice system. Many times children who have been traumatized demonstrate acting out behaviors (defiant to authority figures, anger outbursts and may have an excessive need for control). If they do not receive treatment, their behaviors may escalate to the point that they end up in the juvenile justice system. It will be interesting to follow this bill and see what, if anything, changes.

Laurie Patton

More About Validation

 

One of the factors contributing to the development of borderline personality is living in an invalidating environment during childhood.   Growing up in a home where you are told what you think and feel rather than being allowed to think and feel for yourself.  An all too common example is “stop crying or I’ll give you something to cry about.” You can probably think of other parental statements that communicate that what the child experiences is unacceptable.  These have the effect of undermining a child’s ability identify what they do think, feel, want, fear.   This can create big problems that last into adulthood. 

The alternative is a validating parenting approach in which the child is told “I know that you want that”, I understand that you don’t want to go to bed”, “I can see that you feel sad”, “that makes you angry”.  This does not mean that you agree with the child or allow the child to do harmful things.  It does not impair your ability to discipline or direct.  It does communicate to the child that she is heard and that she is a person who has feelings, wants and preferences.  This is essential learning for children.

Bill

Mindfulness and Marines

 

On Sunday I read an article in the local newspaper that described mindfullness experiments that are being conducted by the Marine Corps.  A goal is understanding the differences in stress responses between groups of Marines trained in mindfulness techniques and those of a control group not trained in the techniques.  The article also addressed the misunderstanding that mindfulness training includes a religious element.  This mistaken belief has kept some people from learning this valuable information.

I have been very impressed with the usefulness of mindfulness in psychotherapy since learning about Dialectical Behavior Therapy (DBT) many years ago.  The work of Jon Kabat-Zinn in researching mindfulness at the University of Massachusetts Medical School has also been important.    I recommend his books, especially Coming To Our Senses.    

Bill

Recovery Bill of Rights Part 4

A Recovery Bill of Rights for Trauma Survivors Part 4

For safety in your personal dependency in therapy you have the right to…

Hire a therapist or counselor as coach, not boss, of your recovery.

Receive expert and faithful assistance in healing from your therapist.

Know that your therapist will never have any other relationship with you – business, social, or sexual.

Be secure against any disclosure by your therapist, except with your consent or under court order.

Hold your therapist’s undivided loyalty in relation to all abusers.

Obtain informative answers to questions about your condition, your therapist’s qualifications, and any proposed treatment.

Have your safety given priority by your therapist, to the point of readiness to use all lawful means to neutralize an imminent threat to your life or that of someone else.

Receive a commitment from your therapist that is not conditional on your “good behavior” (habitual crime and endangerment excepted).

Make clear and reliable agreements about the times of sessions and of you therapist’s availability.

Telephone your therapist between scheduled sessions, in urgent need, and receive a return call within a reasonable time.

Be taught skills that lessen the risk of re-traumatization:

                Containment (boundaries for recovery work);

                Control of attention and mental imagery;

                Systematic relaxation.

Enjoy reasonable physical comfort during sessions.

 

This concludes the Bill of Rights for Trauma Survivors series.  I welcome any responses or reactions that you would like to share.

 

Bill

Crisis Managemet Questions

The Three “What” Questions of Crisis Management

I recently attended a meeting of Mental Health care providers who provide parenting classes for divorcing couples with children. During the meeting, one of the participants shared one of the tools that she uses to help the parents conceptualize how to manage the stress of “crisis” moments. She called it one of the principles of “Reflective Practice,” and to think of it as the most important three “what” questions to ask yourself when something distressing occurs. Specifically, the three questions are: “WHAT happened?”; “So WHAT?”; and “WHAT now?” 

WHAT HAPPENED? This refers to an honest, objective assessment of the event without adding value judgment or other extraneous thoughts about it. Not minimizing or catastrophizing about the event, but describing it realistically. For example, if there has been an accident, describe it. Describe injuries if they occurred. If there has been a fight or disagreement, just describe it. What happened, who did what to whom? Stick to the facts. 

SO WHAT? This refers to the actual consequences of the event, not how you feel about it. If you had an argument with someone and the two of you are not talking, describe it. Refrain from using energy thinking about how the person is a jerk or much you wish you could get even with him or her for treating you badly. If you or someone you care about suffered a financial hardship and paying bills is going to be a problem, describe it. It does not include feelings and judgments such as how unfair it is. Those things might seem very important to you, but they don’t help you actually manage or cope with the situation. 

NOW WHAT? This stage refers to planning what you need to do now given the situation that results from what has already passed. If there is a rift in a relationship that you want to repair, what steps can you take to repair it? If someone has hurt you and is likely to hurt you again, what steps are needed to keep yourself safe? If there has been an accident with injuries, what steps are needed to help heal the injuries in the best manner possible? If you are facing a financial hardship, what steps are needed to cope with it?

Dealing with events or crisis in such a way will free you from the chains that emotional crisis (different from the actual physical effects of the event) place on you. If it helps, write it down using the three “what” questions to help you sort out your response. You will find that a lot of what we think about in stressful situations keeps us from being effective, and actually helps keep the stress, and therefore the suffering, going.

Mark E. Hankla, MA

Children and Trauma

Do children react differently to trauma than adults?

The answer is yes. In adults some of the symptoms of trauma include night mares, flash backs, avoiding thoughts or feelings associated with trauma, detachment, feeling numb, depression, and anxiety.

When children experience a trauma, their reactions may look much different from adults. Younger children may regress. They may revert back to immature behaviors. For instance a child may begin bed wetting, having accidents during the day, or use baby talk. They may act out their scary situation with toys. They may also become clingy. Older children who experience trauma may act out, be defiant to authority, and have an excessive need to control things (and people) around them. They may have anger outbursts, they may steal or hoard items like food or lie. They may lash out at the very people who are attempting to help them. Sometimes, people who don’t understand what is happening in this situation, view the child as a trouble maker, they may think that the child is choosing to be “bad”.

If a child was abused by someone they knew or loved, they may have difficulty having trusting, loving relationships with their safe caregivers. They may unconsciously feel the need to test these relationships to see if the caregiver will protect them. Sometimes they may actually set themselves up to be rejected. For example, a child (who was abused in the home by a family member) may feel distrust of the remaining parent even though that parent stopped the abuse as soon as it was discovered. The child may focus his or her anger at the remaining parent, testing the limits, saying hurtful things, and at the same time be very clingy and dependent upon that parent. As a parent or caregiver in this situation, it can be very frustrating and exhausting.
 

If you are caring for or parenting a child who has been traumatized, please be patient and understanding.  While kids need consistent limits, they also need nurturance, kindness and understanding.

Laurie Patton

 

Coming soon: Tips on how to deal with a traumatized child.

Bill of Rights Part 3

A Recovery Bill of Rights for Trauma Survivors, Part 3

 

Here is our lastest installment in the series.  I found this worthwhile for therapists as well as clients and hope you do too. 

For the integrity of your personal communication you have the right to…

Ask for explanation of communications you do not understand.

Express a contrary view when you do understand and you disagree.

Acknowledge your feelings, without having to justify them.

Ask for changes when your needs are not being met.

Speak of your experience, without apology for your uncertainties.

Resolve doubt without deferring to the views or wishes of anyone.

 

Bill

Recovery Bill of Rights

A Recovery Bill of Rights for Trauma Survivors, Part 2

In my last entry I posted the first part of Thomas V. Maguire’s recovery bill of rights.  This is the second installment.   I hope you find it interesting.

To guard your personal boundaries you have the right to…

Speak or remain silent, about any topic and at any time, as you wish.

Ask for help in healing, without having to accept help with everything.

Take action to stop a trespass that does not cease when challenged.

Choose to accept or decline feedback, suggestions, or interpretations.

Be touched only with, and within the limits of your consent.

Challenge any crossing of your boundaries.

 

Bill

Recovery Bill of Rights

A Recovery Bill of Rights for Trauma Survivors

Thomas V. Maguire published a recovery bill of rights with the National Council for Community Behavioral Healthcare.  I thought I would pass it along in some installments.  Here is the first, I hope you find it useful. 

By virtue of your personal authority you have the right to…

                Manage your life according to your own values and judgment.

                Direct your recovery, answerable to no one for you goals or progress.

                Gather information to make intelligent decisions about your recovery.   

                Seek help from many sources, unhindered by demands for exclusivity.

                Decline help from anyone without having to justify the decision.

                Believe in your ability to heal and seek allies who share your faith.

                Trust allies in healing so far as one human can trust another.

                Be afraid and avoid what frightens you.

                Decide for yourself whether, when and where to confront fear.

                Learn by experimenting, that is, make mistakes.

Bill

Rumination, Mindfulness, and Being in the Moment

One of the most common issues my clients struggle with in therapy is rumination. Rumination can be related to a wide variety of issues and types of emotional responses. For instance, we may feel we’ve been wronged or slighted by someone we “thought” we could trust and ruminate about how and why that person did the perceived dirty deed. During the ruminating the event is played over and over and the initial emotional response is experienced again and again.

Another example would be focusing on a “possible” future event that would be hurtful even though the actual likelihood of the event is inflated due to worrying. I’m sure almost everyone has had the experience of interacting with a family member or friend who was irritable or short with you, and then wondering what you might have done to offend or upset them (even though it may not have anything to do with you at all). What often happens next is rumination about why the other person is upset plus worrying about the next interaction. In this example there are an infinite number of possible scenarios for future interactions to ruminate about, and I will bet none of the ones you imagine are positive, causing negative emotions like anxiety, sadness, anger, and maybe even fear. Consequences for this rumination can include being distracted from current activities which in turn can have any number of negative effects.

Rumination is analogous to suffering and is something we can learn to reduce. There are usually distinct thought patterns that can be identified that can be changed and counteracted. Judgmental thoughts such as “if only,” “why,” “it shouldn’t have,” or “it should be” are often part of rumination. Replacing judgmental statements with acceptance and non-judgmental observation of facts can slow down and counteract rumination. Try visualizing an event you ruminated about in the past and then saying to yourself two types of statements. First say: “That was a very sad and hurtful thing that happened to me.” Then say: “Why does that always happen to me?” Do they feel different to say? Which one sounds like a statement that lets you move on? Which one leaves you feeling unsatisfied and needing to pursue an answer again and again? Learning how to reduce or stop ruminating thoughts will reduce your stress and improve your life.

 

Mark E. Hankla

Taking Hold of Your Mind

People experiencing trauma related problems often say that they have difficulty controlling their thinking.  They may describe being bothered by thoughts that keep intruding on their thinking, or impulses to do things that might be harmful.  Obsessional thinking or going over the same thought repeatedly is another disturbance that can be a big problem.  These, as well as other disturbances in the process of their thinking are often described by our clients. 

While there are a variety of ways to address problems with the thinking process, using mindfulness skills is one that most people can learn and practice.   In her skills training manual, Psychologist Marsha Linehan devotes a major section to mindfulness skills which she titles “taking hold of your mind.”  I find this a fitting title because many people describe the experience of thinking problems as feeling like their mind is out of control. 

One of the first skills that Dr. Linehan covers is called “observe, just notice” which falls into the category of easy to say, difficult to do.  The skill involves observing your thoughts without getting caught up in what they are.  Dr. Linehan says to “…watch your thoughts coming and going, notice each feeling, rising and falling like waves in the ocean.”  I have found another useful metaphor to be that of standing beside a river watching your thoughts and feelings come floating down from upstream, drifting across in front of you and continuing to float downstream out of your awareness.  These and other observe techniques can be very helpful in learning to be in greater control of your thinking.  They are not very easy to use at first and coaching and a lot of practice is usually needed.  I think the time and effort taken to learn and use them is worth it.   I’ll describe more mindfulness skills in future posts.

Bill Bonacker

Acceptance

In the last post I wrote about Dialectical Behavior Therapy’s use of validation.  Another characteristic that Dialectical Behavior Therapy (DBT) emphasizes is the use of acceptance.  Marsha Linehan, the psychologist who developed DBT says that it adds the technology of acceptance to cognitive behavior therapy.  Years after DBT gained popularity, other therapies have included acceptance as a component but I think that DBT is the most organized and systematic in its use.

Dr. Linehan writes about radical acceptance in the DBT Skills Training Manual stating that “freedom from suffering requires acceptance from deep within of what is.  Let yourself go completely with what is.  Let go of fighting reality.” 

In later writing on DBT we find the equation, suffering = pain + nonacceptance.

Swiss American Psychiatrist Elisabeth Kübler-Ross included acceptance in her description of the stages of grief.  She wrote that people confronted with a loss pass through stages of anger, denial, bargaining, depression and acceptance.  Usually people visit the stages a number of times, working through them until they spend most of their time in the acceptance stage.  My clients often find this structure helpful in dealing with problems.  They usually can identify which stage they are stuck in and, with support, figure out what feelings and thoughts the acceptance stage would contain.  Then, of course, there’s the task of getting there.

Bill Bonacker

Validation

Validation

One of the elements that make Dialectical Behavior Therapy (DBT) unique is its emphasis on validation.     Validation can be described as the acceptance of what is.  The common popular comment, “it is what it is” sort of expresses this.  We don’t have to like it, we don’t have to approve of it, we can work to change it but there it is.  DBT’s creator, Marsha Linehan, contrasts DBT’s focus on validation with Cognitive Behavior Therapy’s constant focus on change.  She says that spending most of the time on changing is invalidating to many people.  They can feel that they shouldn’t have their feelings, thoughts or beliefs about what has happened to them.  They can feel that they should be doing better and that their current behavior is bad.  While Dr. Linehan recognizes that change is necessary and important, she stresses that change must be balanced with validation.  DBT’s individual therapy contains structured ways in which validation is used and therapists who have studied DBT are familiar with them.  Skilled DBT therapists are always working to find the balance between validation and change. 

Bill Bonacker

“Why do I have to talk about it?”

Most people who experience trauma do not get Post Traumatic Stress Disorder (PTSD) but those who do get it benefit from therapy.  Sometimes people in therapy for PTSD ask why the therapist wants them to talk about the traumatic experience.  It is usually painful or at least unpleasant so why do it? 

There are several ways to answer that question but brain researchers have recently identified some new reasons.  Psychologist Chris Brewin identified two areas of the brain that can reduce the upsetting effects of remembering a traumatic event.  But, in order to work effectively, these areas need practice.  One of the ways this practice occurs is by finding a way of explaining why the trauma happened – gaining understanding.  Putting it into words is very important in developing the ability to manage the trauma response.  Part of that explanation, or story about the trauma, involves describing how you got from the traumatic experience to the much safer present time.  Skilled therapists who have kept up with the progress in trauma therapy have a growing number of ways to help people through this process.  

If you have read some of the previous posts, you know that the process of treating Post Traumatic Stress Disorder is often difficult.  As we continue to study and learn, our ability to effectively help people with this condition improves.  New research techniques should provide us with much more information about how a traumatized brain operates and how to help people get better. 

Bill Bonacker

Treating PTSD

In a previous post I described the basics of the diagnosis of Post Traumatic Stress Disorder (PTSD).  Now a little about treatment. 

I have found PTSD to be one of the disorders that responds best to treatment.  In the last 20 years (not a long time in the history of mental disorders) there has been a huge increase in the understanding of the problem and the ways of effectively treating it.  The International Society of Traumatic Stress Studies and The International Society for the Study of Trauma and Dissociation have supported much research and training and continue to do wonderful work.  The therapists that I work with have all participated in training from these organizations and I look forward to attending as many of their events as possible. 

We now expect the return of a large number of military veterans from the wars in Iraq and Afghanistan in addition to the people in other occupations who have experienced terrible events.  Some of these people will have problems with PTSD.   In recent news reports, I have heard that there are not yet enough therapists trained to treat these people.  Recent Congressional testimony has addressed this ongoing problem in regard to the resources of the Veterans Affairs organization. 

If you know of someone who might have PTSD (or might be one), it would be a good idea to get it checked out.  There are resources out there, the internet has lots of links and pages for interested people. While some medications can be helpful in the treatment of PTSD, psychotherapy is the primary method of treatment.  Taking a pill won’t make it go away.  When selecting a therapist, ask if they have any specialized training and are aware of the recommended treatments of PTSD (the Standard of Care).  As always, be an informed consumer. 

Bill Bonacker

What is PTSD?

PTSD is the abbreviation for Post Traumatic Stress Disorder, a condition defined officially in the diagnostic manual of the American Psychiatric Association.  PTSD is also increasingly in the news and in popular publications associated with the controversy about whether the diagnosis should be given to some members of the Military Services.  There is some uncertainty and confusion about what it really is and I hope I can add some basic clarity.

Psychologist John Read has said “bad things happen to people and it screws them up” – the basic concept behind PTSD.    The official diagnosis is, of course, more complicated (about 6 pages in my copy of the diagnostic manual) and specifies what “bad things” (trauma) and what kinds of problems qualify.  It is also important to remember that not everybody who goes through a terrible experience has serious problems. 

When people who experience traumatic events do have serious problems they come in particular types.  As I wrote in previous posts, people can experience an increase in the amount of time that their minds and bodies spend “on red alert”, prepared for more trouble.  This kind of problem can be a high level of anxiety or tension, being “jumpy” (we call this an exaggerated startle response), being unable to relax or sleep well, poor concentration and others.

An additional kind of problem that people with PTSD experience is an unwanted remembering of the trauma which can include dreaming about it, feeling like it is happening again and being upset when they run into situations where they are reminded of the trauma. 

The third type of problems involve trying to avoid reminders of the trauma.  We usually see people avoiding people, places or activities that remind them of the traumatic experience, a decrease in feelings (called numbing) drug/alcohol use and other ways of avoiding. 

Bill Bonacker

Coping or Curing?

Coping or Curing?

Being mindful requires that we be realistic and honest with ourselves and others. This is important because people who are facing difficulties such as grieving or anxiety tend to construct contingencies (I often think of them as “alternate realities”) by which they seek to eliminate the source of their distress before they move forward with their life, goals, etc. It’s a sort of “if, then” scenario which they seemingly demand or expect be satisfied before they will return to normal existence. We also refer to it as “bargaining” because it’s as though the situation can be changed for the better if only we can promise something enticing enough for fate to change the outcome.

An often heard comment from many of the people I see in therapy goes something like this: “I feel like I’m being told to just get over it and get back to (work, school, the task at hand, etc.).” In this scenario, it appears that people are waiting for their distress to disappear before they reengage in activities that they find difficult due to their distress. Around and around it goes, because which will happen first? Will they return to normal activities, or will the distress disappear? That is a question that they are unable to answer satisfactorily.

They are often angry, sometimes not so much because they are being asked to fulfill their obligations or duties, but because they believe they are being told to “get rid of” their distress first. This is where I am quick to jump in and totally agree with them. They cannot just get rid of their distress, and it would be totally unrealistic to expect such a thing. But, and this is the tricky part, that does not mean that they can’t still function. The right question to ask is: how does a person learn to cope with distress while fulfilling other obligations? Coping with an issue is NOT the same as resolving an issue. Coping can buy time during which someone can work on resolving the source of their distress, and in the mean time still function at a high level. While it is normal and understandable that people engage in bargaining and contingencies before moving on, ultimately the bargains will not be fulfilled and history will not be rewritten. While the love and support of friends and family can be invaluable, you may sometimes find that you need the help of a professional who understands the subtleties between coping and being cured. Make sure you get the kind of assistance that helps you truly move forward.

Mark E. Hankla