Thread by @neuronbomb

Fresh-faced & feeling a bit better, ready to keep my trauma knowledge fresh and cutting edge. Today and tomorrow I’m tuning into the #TraumaticStress conference through @harvardmed. Time to live tweet!? It’s been ages!

This morning we are starting with a session about trauma, suicidality, and self destructive behaviors. Unsurprisingly, understanding a patient’s affective experience & *their* sense of loss/harm is paramount rather than making assumptions based on our own experiences.

A primary driver of suicidal thoughts or behaviors is “escape from intolerable affect” AKA “shit feels fucking AWFUL and I need to get OUT!” Interestingly, Michel 1994 found patients cite escape from pain while clinicians cite interpersonal reasons as sui motivation — a divide!

“It’s not that I want to die, I was just tired of living.” - the speaker quotes a patient. Absolutely. This is what I see in my practice consistently. Another internal experience she mentions is “aloneness”—huge sense of emptiness, alienation, hideousness, almost not human.

Questions to ask a suicidal patient: what do you believe will happen if you die? What consequences will it have for others? Do you feel it’s an effective solution for your issue? (people who cite “reasons for living“ such as pets/faith, make fewer attempts & have less ideation).

Diya is also bringing in psychoanalytic contributions to our understanding of suicidality. There’s a paper “3 devices of suicide: revenge, riddance, and rebirth” by Maltsberger & Buie (1980 but timeless apparently) that’s pretty valuable in thinking symbolic fantasies for SI.

HOT TIP: if you as a clinician or friend just keep safety planning over and over with someone instead of also discussing anything else in their life, it is likely to make them feel more hopeless and paradoxically increase the suicidality. So don’t do that 😝

Chronic suicidality isn’t the same as acute or active suicidality. So many of my clients & personal communities deal with chronic suicidality — living in this world, it’s not surprisingly! But chronic SI can turn into active SI and those have to be handled differently.

Boom there you go: address the roots of why someone feels this way for chronic suicidality instead of focusing all your energies into the “dangers of completion.” (TBH sometimes these trainings aren’t new info for me, but helpful to show me “yes you’re still doing a good job” 🤣)

She also mentioned that for patients with hella trauma, “higher levels of care” (like inpatient / hospitalization) aren’t always useful and in fact can be damaging and retraumatizing. 👏🏼EXACTLY!!! 👏🏼 She recommends keeping people at the lowest level of care possible.

A thing I wanna plug here is mandatoryreportingisnotneutral.com — because the reality is that WE ARE TAUGHT IN OUR PROGRAMS to reduce our liability & “if you’re worried, report” & that is TRASH cuz so many clinicians are trigger-happy & disproportionately report marginalized ppl needlessly.

Advice? Don’t split hairs, let them know you can’t read their mind, anticipate roller coasters and relapses, discuss dilemmas openly, discuss the meaning of these things for them, “it’s hard to live while planning to die” - so be curious about life vs death orientation.

Another paper “Countertransference of Hate” (again by Maltsberger and Buie, 1978) — which speaks on both aversion and malice *toward patient* which tempts us to abandon our patient & avoid them, & even ignore their SI threats. THIS IS DANGEROUS AF so we gotta pay attention.

I FUCKING LOVE ANALYZING COUNTERTRANSFERENCE. It is so crucial and valuable. That’s partly why I get so cranky when clinicians act like they’re unbiased 🙄 Not only are you lying to yourself but you’re missing out on a TREASURE TROVE of insight for yourself AND your client.

Now she’s talking about documentation it doesn’t have to be mega extensive, but you should share the rationale for decisions especially if they’re more conservative (in the sense of not escalating care). But explain in vs outpatient, med changes, change in freq of sessions, etc.

She says to be specific (“has intermittent passive SI but has no plan or intent to act”), include clinical assessment (“pt is future oriented, sleeping better, less anxious, does not feel impulsive”), & when possible include collateral info (“day program staff note improvement”)

She also says to document that you addressed high-risk symptoms such as anxiety, hopelessness, substance abuse, and how these interventions were received + that you discussed the risks of continuing these high risk behaviors + if you get consultation & supervision.

With some of my clients, I do this humorously, so it doesn’t seem like an inauthentic broken record. Aaand it can also help for note-taking to have little scripts for notes you can copy-paste into records instead of writing them out each time. 🤓

She also points out in some cases, suicidality is an “unconscious wish to satisfy the parental dilemma” (wherein the parents or caregivers DO elicit the suicidality, who overtly or implicitly tell the person they should die or it’s harmful that they exist).🙃😬🙃

Next speaker is Mary Harvey speaking about an ecological view of psychological trauma, recovery, and resilience. Honestly, probably not gonna live tweet much for that one...? But likely a few little nuggets.

The TLDR is, in two tweets: trauma doesn’t happen in isolation and we gotta look at a person’s context, recovery doesn’t always require psychotherapy, art and multimedia processing can be super helpful for people, we all make meaning of our experiences & we gotta discuss those >

You can have “expressions of resilience coexisting with signs of severe trauma,” a goal of clinical intervention is to “foster & mobilize survivors’ access to their resilient capacities,” be anti-oppressive please dear GODDD, the best interventions are embedded in community 😌

Ok here’s a useful slide:

And note—not all of the domains are broken or highly impacted negatively. Part of our work as people and clinicians is to assess these and see which are stronger than others.

FYI: Authority over memory is basically “I have control over recalling trauma memories, and can put them as needed” (vs being flooded or intruded, or not remembering anything / avoiding it all)

Memory + affect integration = you can remember things and FEEL them simultaneously.

Affect tolerance = ability to feel your feelings and tolerate ‘em (low tolerance means you easily get hypo or hyperaroused, aka responding by freezing/sleeping/lethargy or anxiety/agitation/tension etc)

Symptom mastery = how you have symptoms in check or supported

Next talk is about migration and trauma in a U.S. context by Usha Tummala-Narra. This is one I won’t be able livetweet too much but we shall see!

A few nuggets to reiterate: the pandemic has made shit worse, if we aren’t looking at cultural norms when discussing violence we are gonna fuck it up, shit is worse for migrants who come here and are part of racialized groups, the sociopolitical climate plays a HUGE role here.

Based on her research, having a client and the therapist share their ethnic/racial background doesn’t alone predict effectiveness (of course tbh). And more than anything what matters is the therapeutic alliance, a non-exotifying curiosity and willingness to learn, humility, etc

Ok time for next one though I’m suddenly getting a big headache 😫 This sesh is by Fanta Atkinson PhD and Holly Aldrich LICSW, and the focus is homicide. I’m excited for this one because this isn’t an area I’ve done much work in personally. 🤓

Fanta notes “The pinball effect of trauma” & how it’s never just about a primary victim and their family, we also have to think about their friends and neighbors, the service providers and social institutions, the community and witnesses, and future generations.

The unique features of homicidal deaths are the dual experience of terror, horror and helplessness; the violence and intentionality behind it; the condition of the body; known or unknown perpetrators; prolonged criminal proceedings; and media good v bad victim narratives.

Other unique homicidal death features: Intense reenactment thoughts and imagery; re-experiencing the death notifications; fear and vulnerability for self and others; violent dreams/reunion dreams; rescue and revenge fantasies. (Some of these overlap w/ DV/SA & migrant trauma tho)

They mention the importance of language and to stop freaking using language of “time to move on, get over it, good to see your old self, he’s in a better place, wrong time wrong place, it was his time,” because it sucks for most people. Pay attention to what people actually need.

(Forgot the theorist oops) but they note traumatic distress, the thoughts are reenactment, the feelings are fear, and the behaviors are avoidance. Versus separation distress where the thoughts are about reunion, the feelings are about longing and the behaviors are searching.

They note how traumatic grief over time isn’t linear and it’s not a simple stage model where you go boop boop up the stairs of a process. Common themes include being in shock, and comprehension, inability to absorb, replaying, & waiting. (This reminds me of my prez with LTAN!)

They also mention how many people straddle two worlds at the same time, one in which they’re going through the motions and doing daily tasks and then all the deep pain and secrecy and grief not everyone sees. A lot of masking. (This is...most interpersonal trauma though tbh?)

These kinds of traumas also make it hard for survivors/closely impacted parties to empathize with others’ struggles or pain or even care about what others are going through. That’s also normal, but eventually it can & should change over time.

The care has to have a dual focus on trauma and grief, combine self-care strategies with the telling of the stories, expand the lens to create space for possibility, and move from surviving to participating in community of society again.

With people who are dealing with homicide deaths, there’s also simultaneous public & personal narratives about what happened. There’s a *communal* need for safety, reassurance, common telling w/heroes, sense making, unity, & often there is pressure 4 a static linear progression.

On the other hand, the personal narrative of families are usually fragmented and inconsistent. There is an *individual* need for patience, accompaniment, recognition of the all-consuming grief alongside survival, fluidity, and complexity.

“The anguish of homicidal loss is not time-limited; it’s enduring, life altering, and an indelible experience of suffering.” But there are tools to heal! They wrapped with these words they often use:

(A quick moment to be a little sassy here, but someone explain to me how it is trauma informed to have a two day 10am-6pm conference about trauma with only tiny 5 min breaks between speakers and a 30 min lunch break and NO RECORDINGS AVAILABLE AFTER THE FACT? HOOooOoooW?)

Ok next presentation! About “IFS treatment for early trauma and attachment injury impacting adult health” by Nancy Sowell, LICSW. I’m not formally trained in IFS but I do use a lot of these concepts in therapy so I’m curious to hear about how this person conceptualizes it.

Some of the factors that determine impacted trauma especially attachment / youth related trauma? The timing of the event; the severity, frequency, and duration of the experience; and whether supportive, responsive adults were available to help the child.

Her explanation of “why use internal family systems for healing attachment injury.” I especially value number one, “IFS therapy employs a non-pathological multiplicity model of mind.” AKA you can bring in ALL of you versus having to hide or exile shit.

Right now she’s mostly just explaining attachment & describing the “felt sense of security” & the cycles of proximity seeking...which I yell and teach about often enough that I’m not gonna rehash that here 💋

Now she’s talking about how attachment insecurity is linked to physical health problems. Absolutely. (That goes for chronic exposure to trauma and esp childhood trauma as well AFAIK). That’s why you see hella people with chronic and autoimmune illnesses who have a trauma history.

Now we’re on how repeated activation of our stress systems HARMS ALL OUR BODILY SYSTEMS. That’s why chronic stress is SO BAD.

This is why I’ve ramped up my speaking & teaching (and personal habits tbh!) around vicarious trauma, self/community care, organizational changes, etc.

Now we watched a video of her with a client so I can’t really easily tweet that... and shrug idk not much to tweet here.

Final session is The Role of Shame in Trauma by Martha Sweezy, PhD—and I am TIRED and won’t livetweet much but I’ll tryyyyyyy. She’s talking about parts and and IFS again, essentially, actually! She’s discussing how we do a lot of things to address / distract from emotional pain.

She mentions how people often try to hide or address or avoid shame and intolerable emotions via things like risky behavior, suicidal thoughts, drug use, etc etc etc.

How “inhibition (shame) and disinhibition (drug use) are a package deal” and it’s important to be curious.

Q’s she’s posing to the group: “do you have an inner critic? Have you ever felt curious about it & asked why it shames you? Have you ever felt that you valued & loved your critic? Have you ever wished your critic would shut up and go away?”

Two of the most common motives critics site for shaming include “I will improve you before anyone can shame you again” and “if I stop, you would (do a bad thing).”

“Inner critics won’t quit until they believe shaming is not needed and that they will be safe.” She says in her practice the inner critics are often middle school age and dead serious. “They also have no sense of irony and don’t see futility of shaming to prevent shame.”

“The good news for us is that they’re tired, they want help, and we have leverage. Also critics are not their jobs. They can and will change their behavior once they feel safe.”

“the client needs to make the critics’ job obsolete by loving the shamed parts critics protect.”

The Self (however you name it) is curious, calm, confident. When the self can be present & centered attachment injuries can heal. “When vulnerable parts no longer feel shameful, extreme inhibition and extreme disinhibition are no longer necessary.”

“Consider the idea that befriending inner critics will maximize {the likelihood of healing / success}”

She urges clinicians to befriend our own inner critics because we can’t take our patients where we won’t go ourselves. Yessssss.

When that self is in the lead, you have a balanced system. Your exiles are healed, the toxic beliefs are unburdened, there is less reactivity and more choice, and the protectors stand down. (This is all IFS-y language, the “exiles” and whatnot)

In therapy:

📌 think in terms of ✨parts✨.

“if I am more than my vulnerability, I can cherish and protect my vulnerability because my vulnerabilities are parts, not all of me.”

📌 differentiate protectors from exiles by discussing shaming (action) vs. shameful (state/feeling). She notes protective parts do shaming & have motives. Exiled parts feel shameful & want help.

📌 befriend critics w/ curiosity; ask who they protect & what they want 4 that part

Sample questions: “What are you concerned would happen if you stop criticizing? Are you succeeding at what you want to happen here?”

(Yo this is my fav presentation of the day. It’s clear, it has info, it is focused, it has actionables.)

She suggests clinicians assert that the help of the critics was crucial for the client to survive, and suggest that it’s OK to try something new now, including kindness and confidence. (This is the same thing we do in discussing defense mechanisms & their utility in trauma work!)

If / when critics are willing to try new strategies, “rebels will calm down too. Client will feel safer and more spacious and more tolerant of being vulnerable.” (this obviously doesn’t happen overnight but this is the goal / path.) There is a LOT of negotiation that goes on!

Ok time to toot my own horn here—REPEATEDLY in any field I am in, I’m either practicing or collaborating with folks on the cutting edge. Like...repeatedly. Attending conferences going like LOOK AT THIS NEW THING and I’m like “🧐 riiight I have BEEN THERE FOR YEARS, catch up!”

Just thinking about that in sex ed, & how there was nary a mention of pleasure in the big cons when I started, save for a few bold folks, and similar stuff in mental health. And racial justice in sexology, cons like “THIS NEW THING, DIVERSITY.”

me & my folks like 👀 lmao

Like LMAO some of my first co-presentations with someone who’s unfortunately no longer in my life were all about shame and guilt, and about pleasure. I feel so blessed I’ve been able to find the people who have been/are so visionary & worked with them, & continue to do so. 🥰

MORNING TIME FOR ANOTHER MARATHON DAY OF A TRAUMA CONFERENCE

First up: Richard “Dick” Schwartz talking about IFS in treating trauma. This conference has been super heavy on the IFS, unsurprisingly. This presentation is mostly going to be us watching and processing a video of him with a client, so we shall see what I can even livetweet hm.

Something important when trying to access exiles is that we can’t plow through protectors. We need to ASK for permission to access/speak to exiles. Protectors need to feel their job is obsolete, but they don’t just feel that outta nowhere. They have to be assured of safety.

So asking for permission, asking protectors to consider things, and flowing with that versus assuming or just going full steam ahead. Basically all parts need to be validated and the inner hierarchy respected even when the goal is to slowly challenge it. Appreciate the trust.

There’s a lot of pausing, a lot of asking where clients feels that in their body, a lot of closed eyes (though it’s not required AFAIK), asking how the client feels toward each of their parts, “if you were willing to let go of this job or ease up, you could do other things.”

Next session: Michaela Mendelsohn, PhD speaking about group treatment modalities for PTSD. Glad she started off with a thank you to the clients from whom they have learned models & built theory on cuz LORDY LORD clinicians learn a lot and build careers off this knowledge yanno?

So why group work? “One of the most important psychological impacts of trauma is social disruption. There’s a lot of secrecy, shame, and stigma. There is impairment in attachment and relational capacities, as well as functioning. There is also isolation & lack of social support.”

Here she’s describing types of groups, based on the stage model of trauma tx. Stage one trauma groups focus on safety, stability, and self-care. “They are present focused, didactic, & maybe psychoeducational &/or skills-based.” The focus isn’t on individuals’ trauma.

2nd stage is focused on remembrance, integration, and morning. “These are the trauma focused, witnessing centered. They have to be close groups, high cohesion. Active leadership and committed membership is critical.”

Third stage groups are about reconnection: “they have heterogeneous membership, it’s not restricted to trauma survivors, they’re open ended, and they are past/present/future oriented.” There’s more options for these out there cuz you’re past the hump of stage 2!

Here’s more about Trauma Information Groups (stage 1 focused).

TIGs format continued:

And again, in these groups there is active discouragement of going into any specific details about individuals’ trauma.

Okay hm. This prez is actually super chock full of info and specificities. I’m gonna stop livetweeting. If anyone needs the slides *whispers* just let me know. TLDR: group therapy works, group style varies by stage, it can be done via telehealth, they require screening.

Next up we have Amy Dierberger PhD speaking on DBT for trauma survivors.

It’s skill-based and it targets: life-threatening behaviors, treatment-interfering behaviors, and quality-of-life-interfering behaviors. There are various skill modules—I’ll pin them with 📌 (but also like...you can find them here: dbtselfhelp.com/html/dbt_skill…)

📌 mindfulness: “being aware nonjudgmentally of surroundings, thoughts, & emotions. ability to make decisions by using both emotions & facts= ‘wise mind’ (a mix of Reason Mind and Logic Mind, left + right brain)

Learn to: observe, describe, participate in your life *effectively*

We just did a super simple and cool mindfulness exercise about balancing a pen in your hand. Make it challenging enough that you’re having to focus BUT not so hard it’s imposible.

After the 30-60 seconds, ask “how was that for you? What thoughts, if any, came up?”

📌 distress tolerance: Learning to cope with stress in every day life and survive crises without making them worse.

Use:

- distraction,

- improving the moment (explained below)

I Imagery
M Meaning
P Prayer
R Relaxation
O One thing at a time
V Vacation
E Encouragement

- self soothing targeting all five senses,

- STOP (legit just pause),

- TIP (temperature, intense exercise, paced breathing, paired muscle relaxation),

- turning the mind,

- radically accepting/acknowledging the situation.

“Radical means all the way, over and over again. Acceptance/acknowledgement means accepting/ack-ing reality is as it is, not what you wish it would be. Accepting limitations on the future. Accepting life can be worth living even with painful events in it.”

📌 emotional regulation: Learn the definition and function of each emotion, identify invalidate emotions, check the facts and assess whether it’s a justified versus unjustified feeling, etc.

Skills you work on: accumulate positive emotions, build mastery, cope ahead of time (and kind of forecast tough emotions), reduce vulnerability factors (illness, eating, substance use, sleep, exercise)

📌 interpersonal effectiveness: dealing with ppl effectively. This means learning to say no w/o being abrasive & getting what you want from others w/o being demanding. Learn to identify your priority (an objective, the relationship, your self-respect) and proceed accordingly.

To practice, you have to do regular self assessment. This can be a diary to track emotions, target behaviors, safety status, willingness to do these things, use of skills.

Also: personalized distress tolerance & safety plans. So you can recognize red flags, plan ahead, etc.

DBT treatment can happen in a DBT skills group, with a DBT skills coach, by using an individual therapist as a skills coach, bringing DBT worksheets TO providers, etc. multiple ways to get this info and practice.

Ok now next topic is use of EMDR in treating trauma with Deborah Korn, PsyD.

And highlights “the role of the brain’s processing system, guided by the adaptive information processing model which proposes psychopathology is due to a failure of adequately processing traumatic o/ adverse experiences to the point of ‘adaptive resolution’”

“Various forms of bilateral stimulation are used to activate and support the brains info processing system.”

It’s evidence based for PTSD in civilian adults and research is suggesting for CPTSD too.

Interestingly research shows:

Responsibility is a critical component. “We activate/bring in whatever painful core beliefs are there, then we include information that may help unstick them.”

“In EMDR treatment, the therapist is simply helping to mobilize the client’s own inherent healing system.”

Here are the three main hypotheses about how EMDR works (the first one is the *most* solidly backed by current research):

This is also a really info heavy presentation so I’m gonna stop live tweeting. But I’ll share the cognitions slide since it’s valuable even without context:

Next prez! Relational and Attachment Issues in Treating Complex Stress Disorders by Margaret Jarmolowski, LICSW. This is also my extreme jam so I may chill on the live tweeting...?we shall see!

Yeah this is all stuff I already super know and tweet about regularly so I’m taking a break BUT I do want to share this one 🤣

Oh here’s a cool graph tho!

And the other accompanying graph about disorganized attachment mapping.

This is also really good and specific clinical advice:

Ok time for next one! COVID-19 and Trauma by Janet Yassen, LICSW.

Discussing how this relates to acute stress disorder and post traumatic stress disorder: “We aren’t post ANYTHING right now.” 🤣 YUP.

We wrap today with Resilience for Mental Health Providers Working with Patients with Trauma by Barbara Hamm, PsyD.