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Treating PTSD: Natural Disasters, Sexual Abuse & Combat4 CEUs Treating PTSD: Natural Disasters, Sexual Abuse & Combat

Section 14
Appendix: Reproducible Client Worksheets
Based on CD

Answer Booklet | Table of Contents
| PTSD CEU Courses

Trauma Questionnaire
Replay CD track 1 for more information about this technique.
Client answers following questionnaire in a journal or on a sheet of paper.

  1. Have you ever been in a natural catastrophe, such as an earthquake, fire, or flood?  Have you ever experienced a community or work-related disaster, such as an explosion or chemical spill.
  2. Were you ever sexually or physically assaulted, either by a stranger, a group of teenagers, a family member, or anyone else?
  3. As a child, were you physically maltreated with excessive beatings or spankings?  Were a parent’s or caretaker’s disciplinary measures sadistic?
  4. Have you ever witnessed the death, torture, rape, or beating of another person as part of war or crime?  Have you ever seen someone die or be badly injured in a car, airplane, or other such accident?  Have you ever been injured in such an accident?
  5. Has anyone in your family or a close friend been murdered?
  6. As a child, did you ever witness the beating, rape, murder, torture, or suicide of a parent, caretaker, or friend?
  7. Have you ever been in a situation in which you felt that you or a member of your family would be harmed or killed?  Even if your life or the lives of your family members were not directly threatened, did you distinctly fear that you or they were in serious danger? 

Trauma Reexperiencing Quiz
Replay CD track 2 for more information about this technique.
Client answers the following questions in detail to help you and them understand just how the trauma is manifesting itself and affecting their lives. 

  1. Do you, on a persistent or recurring basis, find yourself having intrusive or voluntary thoughts of the traumatic event?  Do you find yourself thinking about the trauma when you don’t mean to or when you are trying hard not to think about it?  Do visions or pictures of the trauma pop into your mind?
  2. Do you have dreams or nightmares about the event?
  3. Do you have dreams or nightmares that are not replays of the actual event, but that take place in the location where the event occurred, contain some of the actions involved in the event, or include some of the feelings you felt during the event?
  4. Do you find yourself suddenly acting or feeling as if you were back in the original trauma situation?  For example, do you have flashbacks, visions, or hear sounds of the event?  Do you have waves of strong feelings about the trauma or otherwise feel as if you have just lived through the trauma again, even without having a flashback or a vision?
  5. Do you become extremely upset at people, places, or events that resemble an aspect of the original trauma?
  6. Do you become distressed around the anniversary date of the trauma?

Calming Breath
Replay CD track 3 for more information about this technique.
Client completes the following exercise when he or she feels their breathing getting shallow in response to a trigger.

  1. Breathing from your abdomen, inhale slowly to a count of five.  Count slowly as you inhale.
  2. Pause and hold your breath to a count of five.
  3. Exhale slowly, through your nose or mouth, to a count of five, or more if it takes you longer.  Be sure to exhale fully.
  4. When you’ve exhaled completely, take two breaths in your normal rhythm, then repeat steps 1 through 3 in the cycle above.
  5. Keep up the exercise for at least five minutes.  This should involve going through at least ten cycles of in-five, hold-five, out-five.  Remember to take two normal breaths between each cycle.  If you start to feel light-headed while practicing this exercise, stop for 30 seconds and then start again.
  6. Throughout the exercise, keep your breathing smooth and regular, without gulping in breaths or breathing suddenly.
  7. If you wish, each time you exhale, you may want to say “relax,” “calm,” “let go,” or any other relaxing word or phrase silently to yourself.  Allow your whole body to let go as you do this.

Easy Questions
Replay CD track 3 for more information about this technique.
Use the following format when addressing clients of a young age or with a mental handicap who cannot understand the concept of hypervigilance.

  1. Is it hard to fall asleep or stay asleep at night?  Do you have bad nightmares?  Do you sometimes wake up and your sheets are all over the bed?
  2. Do you sometimes get mad for no reason?  Do you sometimes get so mad that you throw things or break things?  If you do get that mad, do you feel you can’t feel better until you’ve broken something?  Do you ever shout at your family or friends?
  3. Are you always afraid something might happen to your friends or family now?  Do you feel like they are always in danger?
  4. Do you jump at loud noises?

Identification of Self-Blame
Replay CD track 6 for more information about this technique.
Client answers the following questions about their trauma to identify any traces of survivor guilt or self-blame.

  1. In what ways, large or small, do you blame yourself for the event’s occurrence?
  2. Do you blame yourself for the way you acted or didn’t act during the trauma?  If so, why?
  3. Do you feel responsible for the extent of the injuries or the damage or other negative results of the trauma?  In what ways?

Eating Disorders Questionnaire
Replay CD track 6 for more information about this technique.
Client answers the following questions about their eating habits.  If client answers positively to questions 1-4, the client is told that these are the characteristics of anorexia nervosa.  If client answers positively to questions 5-8, the client is told that these are the characteristics of bulimia.  If client answers positively to questions 9-13, the client is told that these are the characteristics of a compulsive overeater.

  1. Is your body weight 15 percent below that expected for your age and height?  You can find this information out on many BMI or body mass indexes available online.
  2. Are you intensely afraid of gaining weight or becoming fat, even though you are truly underweight?
  3. Do you believe you are fat or overweight even though, in reality, you are not?  Do parts of your body “feel fat” to you, even though the bathroom scales, other people, or your own eyes tell you that those parts are very thin?
  4. If you are a woman, have you missed at least three menstrual periods in a row?
  5. Do you frequently binge?
  6. When you binge or overeat, do you feel as if your eating is out of control—that you can’t stop even if you wanted to?
  7. Do you regularly make yourself vomit, use laxatives or diuretics, diet or fast, or exercise strenuously in order not to gain weight?
  8. Are you obsessed or overconcerned with your body shape and weight?
  9. Do you often feel depressed, guilty, angry, or inadequate?
  10. Do you eat large quantities of food in a short period of time?
  11. Do you eat in secret, hide food, or lie about your eating?
  12. Do you feel guilt and remorse about your eating?
  13. Do you start eating even when you are not hungry?

Primary Effects of Secondary Wounding
Replay CD track 7 for more information on this technique.
Client answers the following questions concerning situations in which he or she encountered secondary wounding.

  1. Did it alter your views of you social, vocational, and other abilities?
  2. Did it change your attitudes towards certain types or gourps of people and/or certain government and social institutions?
  3. Were your religious or spiritual views affected?
  4. Did it affect your family life, friendships, or other close relationships?
  5. Did it alter your ability to participate in groups or belong to associations or your attitudes towards the general public?
  6. Now, review the attitudes you just listed and ask yourself, “Which of these attitudes do I wish to retain?  Which of them are in my best interest to reconsider?  Which ones would I like to discard because they hamper my life in the present?

Trigger Coping Questionnaire
Replay CD track 9 for more information about this technique.
Client answers following questions related to their trigger and trigger coping style to help develop goals.

  1. What are your fears about this trigger?  Cho answered, “I have fear that I will embarrass myself and throw up in sight of strangers.”
  2. How have you usually reacted in the past?  Cho wrote, “I run to bathroom or run away from the smell.  I get angry, too.  In prison, I screamed and cursed the guards.  I tried to throw up on them when they beat me.  When I smell the rice, I want to tell people around me that I hate them.”
  3. What have been the costs of avoiding this trigger or of handling the trigger with fear, anger, or other emotions associated with the trauma?  Cho answered, “My favorite foods are Asian foods.  I can’t eat at Asian restaurants with friends anymore.”
  4. How would you like to react in the future?  Cho wrote, “I want to be happy with my friends and eat the foods I like and go to restaurants I like.”
  5. What do you stand to gain if you react in a way you feel would be more beneficial?  Cho responded, “I would have more friends.  I would be happy and forget the prison.”
  6. How can you break down this trigger so you can face it more easily?  Because she had trouble with this step, we worked out a system together.  Cho decided to stand outside a restaurant that cooked rice for no more than five minutes while practicing some of the relaxation techniques we will discuss later.  Then, when she could cope after five minutes, she stood there for ten.  Eventually, she entered the restaurant itself where the smell was the strongest.  Gradually, Cho reduced her fear of the trigger, rice, but could never fully bring herself to eat it again, understandably.  However, the negative effect it had on her social life diminished and she could even sit at the same table while those around ate it.

Abdominal Breathing Exercise
Replay CD track 9 for more information about this technique.
Client completes the following deep breathing exercise to relieve tension resulting from a trigger attack.

  1. Note the level of tension you’re feeling.  Then place one hand on your stomach right beneath your ribs.
  2. Inhale slowly and deeply through your nose into the “bottom” of your lungs—in other words, send the air as low as you can.  If you’re breathing from your abdomen, you hand should actually rise.  Your chest should move slightly while your abdomen expands. 
  3. When you’ve taken in a full breath, pause for a moment and then exhale slowly through your nose or mouth, depending on your preference.  As you exhale, allow your whole body to just let go.  You might like to visualize your arms and legs going loose and limp like a rag doll.
  4. Do ten slow, full abdominal breaths.  Try to keep your breathing smooth and regular, without gulping in a big breath or letting your breath out all at once.  Remember to pause briefly at the end of each inhalation.  Count to ten, progressing with each exhalation.  The process should go like this:

               Slow inhale…pause…slow exhale (count one)
               Slow inhale…pause…slow exhale (count two)
And so on up to ten.  If you start to feel light-headed while practicing abdominal breathing, stop for 30     seconds and then start up again.

  1. Extend the exercise if you wish by doing two or three sets of abdominal breaths, remembering to count up to ten for each set. 

Self-Forgiveness Examination
Replay CD track 10 for more information about this technique.
Client completes the following questions to help them identify any feelings of guilt that they still may be harboring.

  1. Looking back over the trauma, for which behaviors, attitudes, and feelings do you still castigate or blame yourself?
  2. What would it take for you to forgive yourself for some of these behaviors, attitudes, and feelings?
  3. Is it possible for you to do whatever you have listed above so that you can forgive yourself?  If so, what is keeping you from pursuing whatever you need in order to make peace with this part of your past?
  4. Is there information you need that you might never be able to obtain before you can forgive yourself?  If so, your options are to try to forgive yourself anyway or to continue to punish yourself.  Who are you helping and what good are you doing in this world by punishing yourself?  Who would you harm if you forgave yourself?

Counting Method
Replay CD track 11 for more information on this technique.
Client gets one hundred seconds to emotionally recall a traumatic event.  Therapist counts to one hundred.

  1. Schedule this exercise at the beginning of the session so that you have enough time to discuss the emotions and recall during the rest of the session.
  2. Identify which traumatic memory the client wishes to recall. 
  3. Ask the client to recall the memory mentally and not to speak of what he or she is remembering.
  4. Begin counting from 1 to 100, keeping your eyes on the clock and counting off one number each second.
  5. At 93 or 94, say such statements as, “Back here” to assist the client’s return to reality.
  6. If the client appears dazed or confused, he or she had been able to recollect a trauma. 
  7. Reflect on the emotions the client underwent and try to end on a positive note. 

Gestalt Chairs
Replay CD track 12 for more information about this technique.
Client completes following exercises to help release feelings of guilt and blame.

  1. Arrange two chairs facing each other at an angle and have the client sit in one.
  2. Ask the client to take two, easy, deep breaths.  Tell them to relax and calm themselves as they prepare to touch honestly with their feelings. 
  3. Tell the client to imagine the target of their anger sitting in the other chair.  Ask them to notice what it is like being with this person. 
  4. Ask them to begin a dialogue starting with a positive statement. 
  5. Then ask them to move on to explain what they want. 
  6. Ask the client to tell their target what they are thinking or feelings by describing what happened and the impact of the offense. 
  7. Ask the client to change seats and ask them to voice the feelings of the target. 

Percentage of Responsibility
Replay CD track 13 for more information about this technique.
Using the following format, the client relates how he or she contributed to the traumatic event.

  1. Verbalize the details of the event in the first person. 
  2. What percentage of the event are you responsible for?  Are you sure?  Is it possible that the percentage is more than that; or less?
  3. Who else shared responsibility?  Others at the scene, people distant from the scene?  Societal influences? 
  4. Recalculate responsibility so that the total is 100 percent, and accurately focus on what you did and did not do.
  5. Describe how much you have suffered for the responsibility you have assigned yourself.

Taking Inventory
Replay CD track 14 for more information about this technique.
Client completes the following questions regarding his or her progress during therapy.

  1. What have you learned about how the conditions of trauma distorted your view of what occurred during the trauma, your role in causing the trauma, or influencing its outcome, your self-esteem, and you view of other people?
  2. What have you learned about yourself emotionally?
  3. Which emotions do you still struggle with?
  4. What are your most trying emotional situations today?
  5. Do you have any unfinished emotional work to do regarding the trauma or secondary wounding experiences?  If so, what?
  6. How did the trauma change your view of the meaning of life?
  7. How did the trauma change your view of human nature?

Refinding Yourself
Replay CD track 14 for more information about this technique.
Client answers the following questions regarding his or her life before the traumatic event.

  1. What did you do for fun?
  2. What were your major worries and anxieties?
  3. What did you like about yourself then?
  4. What didn’t you like about yourself?
  5. Who were your friends?
  6. How were you getting along with your family?
  7. Did you have any religious or spiritual beliefs?  If so, what were they?
  8. Did you have any firm philosophical or existential convictions?  If so, what were they?
  9. What dreams or goals did you have for your life, and what were your interests?
  10. Of the goals and interests you had prior to the trauma, which ones would you like to pursue now in the near future?
  11. Of the pretrauma goals and interests you are still drawn to, which would you realistically be able to pursue?  What obstacle would stand in your way?

Accentuating the Positive
Replay CD track 14 for more information about this technique.
Client completes the following steps to aid in building their self-esteem.

  1. Develop a list of ten positive statements about yourself that are meaningful, realistic, and true.
  2. Write these ten statements on a piece of paper. 
  3. Find a place to relax for fifteen to twenty minutes.  Meditate upon one statement and the evidences for its accuracy for a minute or two.  Repeat this for each statement.
  4. Repeat this exercise for ten days, adding an additional statement each day.
  5. Several times each day, look at an item on the list, and for about two minutes meditate on the evidence for its accuracy.
 
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