Advanced Webinar Program

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1 Advanced Webinar Program Working with the Effects of Dysregulation: Janina Fisher, Ph.D. Hyperarousal-Related Symptoms: Action-oriented behavior: impulsivity, risk-taking, poor judgment, acting out Perceptual and muscular hypervigilance, desperate desire for help Flooding: intrusive images, emotions, and sensations Fight/Flight responses: self-destructive, aggressive, and addictive behavior Hyperarousal Optimal Arousal Zone: feelings can be tolerated able to think and feel Hypoarousal Ogden and Minton (2000); Fisher, 2006 *Siegel (1999) Hypoarousal-Related Symptoms: Flat affect, numb, feels dead or empty, not there Safety lies in staying numb and inert Cognitive functioning slowed, lazy Preoccupied with shame, despair and self-loathing Disabled defensive responses, victim identity Fisher, 2005 Self-injury, more rigorous restricting, harder drugs to replace the substances that no longer work Increased activation and overwhelm when drug effect wears off The only answer left now is suicide Clients start to engage in compulsive behavior or substance use to lower arousal And intrusive images, panic attacks, night terrors Triggered by everyday stimuli, survivor becomes uncomfortable, overwhelmed, reactive, impulsive The natural reaction is to isolate to avoid potential triggers But isolation impairs stimulus discrimination, causing more triggering Leading to even more strenuous attempts at avoidance Do Not Copy without Permission 1

2 Addictive behavior arises not as a pleasure-seeking strategy but as a survival strategy: To self-soothe and self-regulate To numb the hyperarousal symptoms: intolerable affects, reactivity, impulsivity, obsessive thinking To combat helplessness by increasing hypervigilance and feelings of power and control To treat hypoarousal symptoms of depression, emptiness, numbness, deadening In the service of walling off intrusive memories As a way to function or to feel safer in the world Fisher, 2008 Jan, recalling abuse at age five: Every day, I would say to myself, I can die tomorrow. I got through each day by promising myself I could die the next day. Annie, recalling how cutting helped her to function: I would cut myself to get off the floor of the closet and go downstairs and make dinner for my family. Anita, recalling a hospitalization at age 13: After I got out, I went to a party and had my first beer. I thought, If I have beer, maybe I won t have to go back there again. Peter: I survived as a kid by locking myself in my room and eating and masturbating til I got numb. Hyperarousal symptoms: Alcohol and marijuana induce relaxation and numbing, facilitate social engagement by decreasing hypervigilence, and allow sleep. Cocaine, speed, and crystal meth counteract relaxation effects or maintain hypervigilance. Heroin dampens rage and impulsivity, while ecstasy combines relaxation with increased energy Hypoarousal symptoms: Speed, cocaine, ecstasy and crystal meth counteract feelings of deadness, numbing, hopelessness and helplessness, while marijuana and other downers maintain the hypoarousal. Alcohol, at different dosages, can induce numbing or counteract it. Although a depressant, alcohol in small doses has a stimulating effect Fisher, 2003 Do Not Copy without Permission 2

3 Eating disorders: over- and under-eating both induce numbing effects, while purging results in a temporary increase in arousal followed by profound hypoarousal Compulsive sexual behavior: sexual addiction increases feelings of interpersonal control, counteracts hypoarousal during seduction phase and induces relaxation during post-coital phase Self-injury: self-harm produces both an adrenaline and endorphin response in the body, increasing energy and feelings of power and clarity and also buffering the pain As in substance abuse, prolonged use of these behaviors leads to tolerance: more and more is needed to achieve the same effect Fisher, 2003 Hyperarousal Hyperarousal is decreased by: alcohol, marijuana, heroin, overeating or restricting, cutting, planning suicide or self-harm, self-sacrifice and caretaking Window of Tolerance * Optimal Arousal Zone Hypoarousal Ogden and Minton, 2000, Fisher, 2004 Hypoarousal is decreased by: cocaine, speed, high-risk behavior, cutting, suicide planning, re-enactment, re-victimization, hyper-reactivity Sobriety or abstinence only address the addictions issues. When behavior has been a post-traumatic survival strategy, new challenges now arise The client now faces not only the risk of relapse but the risk of post-traumatic flooding, autonomic dysregulation, increased impulsivity, overwhelming emotions, and flashbacks, all of which predispose the client to relapse Treatment must address the relationship between the trauma and the addictive behavior: the role of the addictive behavior in medicating traumatic activation, the origins of both in the traumatic past, and the reality that recovering from either requires recovering from both Fisher, 2007 Do Not Copy without Permission 3

4 Hyperarousal: over-activation creates chronic de-stabilization and desperate craving for relief The addiction has facilitated a false Window of Tolerance: the client is missing any other way to self-regulate Window of Tolerance in sobriety Hypoarousal: numbing, deadness and passivity contribute to need for substances to either shift or maintain this state Sensorimotor Psychotherapy Institute Fisher, 2009 Increased acting out, unsafe behavior Substance or behavioral relapse negative effects of addiction Sobriety or Abstinence as a panicked attempt at self-regulation loss of chemical support emotional overwhelm, irritability, reactivity, flooding, sensitivity to triggers matches increase in PTSD symptoms Increase in PTSD symptoms Increase in addictive impulses or behavior Increasing the ability to be mindful rather than judgmental: mindfulness regulates arousal, wakes up the frontal lobes, increases self-awareness, and allows observation of patterns that feed addictive behavior Building curiosity: since curiosity regulates the nervous system, it lessens needs to act out Focusing on the relationships between trauma-related emotions and body sensations and compulsive behavior: e.g., by learning to observe overwhelming feelings and impulses, increasing ability to notice the relationship between triggers, symptoms, and addictive behavior Fisher, 2013 Do Not Copy without Permission 4

5 Offer a crash course on addictions/eating disorders as attempts to self-regulate and on the Abstinence/Relapse Cycle Normalize feelings/behavior that have been sources of shame as ingenious attempts to cope Label the symptoms as symptoms : poor judgment and impulse control ( I can t help it ), self-loathing, self-neglect Increase awareness of post-traumatic triggering and habitual triggered survival responses: getting the logic of trauma decreases shame/increases understanding of cause-and-effect Encourage curiosity and compassion: That makes sense, Of course you feel trapped at AA meetings, 12-step programs are just another treatment, and all treatments have side effects Fisher, 2003 In the context of having used: I m so glad you could tell me you used last night what triggered you? What was going on just before you used? How could you tell people were getting to you? That they had no respect? That s a pretty big trigger! People who don t do their jobs, so you have to carry all the load I don t know I just hate my job People were getting to me they have no respect One after another, they weren t doing their jobs I can t rely on anyone Yeah, just like I have my whole life... Fisher, 2008 Connecting Symptoms to Triggers, cont. In the context of having used: When you got triggered, what feelings came up? I just wanted a burger and a beer So the trauma trigger triggered the food trigger! F--- it! I don t have to feel this shit Well, drinking does calm the nervous system you were just trying to make the feelings disappear But now I m feeling stupid, and my head is killing me, and I don t want to lose my wife We have to figure out a way for you to know you re triggered. People are going to be assholes sometimes you don t want to relapse over them That s for sure. They re not worth it Fisher, 2008 Do Not Copy without Permission 5

6 Got a voic from my father My hands were shaking went into kitchen and started eating ice cream Hyperarousal Made a peanut butter sandwich and then another Window of Tolerance After I threw Optimal up, Arousal I Zone felt better Came home from training feeling OK I felt better, then the phone rang again! Felt sick and disgusting Hypoarousal And then I curled up on the couch and slept Adapted from Ogden and Minton (2000) Fisher, 2009 Re-framing asks: how might the symptom be adaptive or have adaptive intent? E.g., using cocaine or pot before going to work might alleviate anxiety; the anorexic part of the system might be trying to numb overwhelming feelings and sensations Addictions capitalizes on body chemistry: Of course, weed gives you relief: your body starts making neurochemicals that take the edge off the pain and make you feel more in control; When your risk-taking part drives that fast, you pump adrenaline; Speed really helps with the hypervigilance, did you know that? Celebrate the survival resources (Ogden, 2000): appreciation of survival strategies challenges habitual beliefs of inadequacy and also allows the therapist to befriend acting out and addicted parts Fisher, 2008 Heighten the client s curiosity about the role of addiction in his or her survival: what was the timing of the initial attraction to drugs? How did the eating disordered part help her to cope? How did later stressors impact addictive behavior? Re-frame the history by assuming that the addiction had meaning and purpose: How did the addiction help you to be less afraid? Able to go to work? Or go to sleep? To handle being around people? To act like everything was normal? Re-frame the relationship between PTSD and addictive behavior: The cocaine helped you to feel less numb, didn t it? So, you drink in order to sleep at night that makes sense you can t sleep, but you can pass out, It makes sense that you needed the speed to be hypervigilant enough to go out Fisher, 2005 Do Not Copy without Permission 6

7 Even relapse behavior can be re-framed as a golden opportunity or as a spiritual opportunity, thereby challenging habitual shame responses to relapses Clients are asked to assume that the relapse is sending a message: If this relapse was sending you a message, what would it say? That you didn t have enough support? Or you missed the early warning signs? You didn t see the trigger? You didn t want to deal with the scared part? Rather than focusing on the negative effects of the relapse, the new learning is celebrated, and the client asked to practice these new responses Fisher, 2008 Because traumatic triggering activates inhibits prefrontal activity, the therapist cannot expect the client to remember the coping plan or to use a cognitive map or generalize the skills and knowledge, unless there has been consistent rehearsal in sessions In sessions, therapist and client must practice the art of cognitive over-ride: e.g., practice using the language of triggering to describe activation, practice the art of keeping three frontal lobe cells awake and mindful to observe the triggered experience, or practice the use of distraction or container techniques in response to the feelings and activation that arise in therapy Fisher, 2006 Trauma survivors typically have elevated hypervigilance but poor anticipation skills. They anticipate the worst but fail to prepare for it Clients can learn to anticipate by mindfully analyzing each crisis: looking for triggers, early warning signs, selfsabotage, failures to utilize appropriate coping skills In preparation for upcoming events, the therapist must help clients anticipate potential triggers and rehearse skills and responses needed to prepare for the challenge Anticipation also decreases the negotiating currency of unsafe behavior: rather than focusing on the crisis du jour, the work is focused on prevention of crises with the therapist as a guide and mentor rather EMT Fisher, 2009 Do Not Copy without Permission 7

8 Articulate the conflict between safety and unsafety: the loss of control, of familiarity; the prospect of intrusive feelings; the fear of becoming overwhelmed or feeling weak Acknowledge what the patient is sacrificing in choosing safety: loss of immediate relief, loss of control, loss of the friend who is always there, loss of a social network Foster a de-coding approach to acting out or unsafe behavior: finding the trigger, creating a frame-by-frame deconstruction of triggers and reactions Bore the patient into health (Kluft) by a relentless focus on deconstructing crises, anticipating triggers, and developing increased ability to separate self from the part or symptom Fisher, 2009 Traumatic Reactions: Shaking, trembling Numbing Hypervigilance Agitation, desperation Collapse, shame Impulsivity Somatic Resources: Deep breath, heavy sigh Relaxation, opening Lengthening the spine Focusing on the sensations Making a movement Physical support (eg, chair) Pulling back from help Grounding on the floor Sensorimotor Psychotherapy Institute Breathing, sighing, releasing tension or taking in calm Taking walks, being physically active, yoga, tai chi, jogging Watching calming TV shows: eg, the Nature channel Engaging in any safe activity that calms the body (taking a bath, making cookies, ironing, knitting, drawing, playing with a pet) Engaging in activities that require concentration but not much thinking (tanagrams, jigsaw puzzles, computer games, solitaire) Working with the hands (gardening, cooking, needlework, painting) Prayer and meditation, listening to guided visualization tapes Inspiration: finding one thing that makes you smile Using mantras or sayings: This too shall pass, One day at a time Copyright 2001 Janina Fisher, PhD Do Not Copy without Permission 8

9 Coping with feelings Coping with impulses Read meditation book--call a friend--- go over coping skills cards---go to a 12- step meeting---watch The Lion King Don t be alone---go over Ten Things to Do list---call my sponsor---breathe--- live a minute at a time---call the hotline Coping with action plans Call my therapist---make sure I am in a safe place---go to the ER---re-read my contract---use my Survival Kit Fisher, 1999 Make a Coping Skills Chart A little depressed and anxious Starting to hate myself, say bad things, feel shaky and agitated Wanting to hurt myself, feeling like no one cares: I m all alone Starting to feel suicidal, having fantasies about my funeral Hoarding pills, buying razor blades, know that I am not safe Use distraction: go for a walk, listen to music, read a magazine Remember to breathe! Go over 10% solutions list, try to relax Find someone to talk to, even about the weather. Try not to be alone. Use Safety Nets, remember that this is my way of coping with pain. Remember that the pain will pass Talk to staff, go to the ER, give someone anything that I shouldn t have right now Fisher, 1990 A Survival Kit contains a variety of objects that are symbols of a reason to live or of what keeps me connected to the universe, what keeps me keeping on: Poems or prayers or inspirational sayings Pictures of loved ones (family, friends, pets) Letters, cards, tapes given by friends or caregivers Crystals, stones, seashells, driftwood, beach glass A stuffed animal or other comforting, beloved object Coping skills chart, safety contract, What to Do list Fisher, 1995 Do Not Copy without Permission 9

10 If self-harm, eating disorders, addictive behavior and suicidal ideation are all attempts to self-regulate, it is important not to treat them simply as life-threatening. We need to distinguish life-threatening unsafe behavior and behavior aimed at self-regulation The therapist should not assume that all of these addictive behaviors are intended to be life-threatening but should inquire: How does this help? What does it do? Self-injury is rarely life-threatening. If we respond as if it has suicidal intention, we may unintentionally exacerbate it. We will dysregulate the client and over-protect, robbing the client of the opportunity to regulate her- or himself Fisher, 2009 Active suicidal ideation and creating suicide plans may be indicators of unsafety, but not always. Some trauma clients have suicide plans for many years without ever making an attempt. With planning and active ideation, the therapist should be curious and concerned without conveying alarm. Our alarm increases dysregulation instead of modulating it What should we be curious about? Curious about how long the client has had the plan, about what has triggered the increased intensity of suicidal longing, about how impulsive or desperate the client is feeling, about whether or not s/he is seeking death or just relief from overwhelm Fisher, 2009 Therapeutic contracting is complicated because of issues of power and control: as therapists, we want to avoid becoming the patient s external locus of control, their reason to live Contracts also carry two risks: first, suicidal clients often acknowledge that they would not feel bound by any contract, so contracting can feel like a lie. Secondly, being asked to contract can be experienced as entrapping Commitment to the work of recovery or to choices that enhance safety are most helpful: e.g., committing not to isolate, go to 12-step meetings, or go to appointments. Time-limited commitments are also better than open-ended contracting: I can keep myself safe until tomorrow morning... Until I go to work... I commit to using my Survival Kit... To not being alone... To follow my safety plan Fisher, 2009 Do Not Copy without Permission 10

11 Failing to validate the relief offered by addictive behavior Failing to understand the fear of relying on people and the safety in relying on a substance or behavior under your own control Failing to see that care of the body is not a priority for the trauma survivor: when your body only matters as a vehicle for discharging tension, its care becomes meaningless Failing to convey that trauma-related shame and secrecy will make it feel normal to lie/evade and unsafe to disclose Becoming engaged in a struggle in which the therapist becomes the spokesperson in favor of sobriety and the patient the spokesperson for addictive behavior, neglecting the task of helping the patient to struggle with the strong internal opposing forces Copyright 2006 Janina Fisher, PhD For further information: Janina Fisher, Ph.D College Avenue, Suite 220C Oakland, California DrJJFisher@aol.com Sensorimotor Psychotherapy Institute Do Not Copy without Permission 11