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PTSD & other Traumas: Ethical Issues in Using Recall

Section 10
Intrusion Management

Question 10 | Answer Booklet | Table of Contents | PTSD
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

Flashbacks
The following skills can help defuse the distress of flashbacks, an especially troubling type of intrusion, although the techniques can be helpful for any forms of intrusions.

1. If flashbacks occur when your eyes are closed, open them and perform about twenty-five cycles of the eye movement technique. If opening your eyes is not practical, do it with them closed. Although some people find that simply closing their eyes tightly distracts from the intrusive thoughts, most people find they cannot get oriented to the present and away from reliving the past without seeing where they are.
2. Ground yourself. This means to do things to bring your awareness solidly back to the present. Rub fabric or the arms of the chair. Notice what your body feels like. Notice colors or other details in your surroundings. Name items in your surroundings. Push your feet down or stomp them. Rub a ring or another piece of jewelry that you associate with someone safe or a safe time in your life. Say to yourself, “That was then, I am here, this is now.” Count something, like beads.

Repeatedly tell yourself:
• This is just a memory from the past—old stuff. It will pass.
• My feelings are understandable. They come and go.
• I am safe now.
• That was then. This is now.
• I’m here now. Today is _____ (think of today’s date).

You might also exercise, take a shower, play with pets, focus on breathing, or take a nap.

Safe Place Imagery
The object is to create a safe place in your imagination, a haven or place of rest. This skill is very effective anytime that you feel overwhelmed during or between sessions. It is also a pleasant way to start the day, and is frequently used for restoring calmness at the end of a therapy session.

1. Select an image that evokes calm and safety (not the safe place yet; just some image that makes you feel safe and calm).
2. Focus on the image. Feel the emotions. Identify the location of the pleasant sensations in your body. Just allow yourself to experience and enjoy them. (Therapist allows time and asks you to signal when you feel the soothing emotions and sensations. She asks you to identify where in your body you feel the sensations.)
3. Now bring up the image of your safe place, the place that feels safe and calm to be in. Your safe place can be real or imagined, outdoors or indoors. Maybe you have really been there or maybe you’ve made it up. You may go there alone, or some person that makes you feel safe can be there. You are the boss. If you can’t think of a safe place, then imagine the safest place you can think of.
4. Notice all your physical senses in that safe place. Notice where you feel the pleasant sensations in your body and allow yourself to enjoy them. Now concentrate on those sensations.
5. What single word fits that picture (you might pick a word such as relax, beach, mountain, trees, etc.). Think of that word and scene, allowing yourself to again experience the pleasant sensations and a sense of emotional security.
6. Self-cueing. Repeat the procedure on your own, bringing up the image and the word and experience the positive emotions and physical sensations.
7. Self-cueing with disturbance. You can use this technique to relax during stressful times. To emphasize this point, bring up a minor annoyance and notice the accompanying negative feelings. Now use your cueing word and bring up the emotions and physical sensations of peace and safety.
8. Bring up a disturbing thought once again and access your safe place on your own.
9. Practice at least once daily. Call up the positive feelings, word, and image while you use the relaxation techniques that you like best.

You might wish to be creative. You might envision the safe place nearby with a door you can open and step through into the scene. Take a nice relaxing breath before entering. You might find a couch there, next to which is a feelings dial. You might rush there to tell your concerns to the safe person, or just go to be safely alone.

Feelings Dial
You can use this imagery to gain better control over the intensity of your feelings. With practice, you can learn to “turn down” overwhelming feelings. (This technique is not a way to avoid or get rid of feelings—these must eventually be processed for healing to occur.) Imagine a volume dial, say on a radio. This is like a “feelings dial.” It has numbers from 1 to 10, from low to most intense. Notice what the dial is made of. Notice if it is smooth. Think of an unpleasant feeling you sometimes feel. Notice whether you are feeling it right now.

What number on the dial reflects how weak or strong the feeling is now? What number is the dial on now? What is that like to be on that number? What would it be like to be at 1? Or 8? How about somewhere in the middle? If you’d like to try turning down the feelings dial, what number would you turn it to? Turn down the dial lower and lower until it goes down a number. And keep turning it lower and lower and lower. Would you like to keep going? Keep going nice and slow until you find your desired intensity.

Please repeat several times so that you can master this skill. Do easy deep breathing. Time your breathing so that each time you exhale, you turn the dial a little lower.

Anytime that your feelings are too high, imagine the dial. Turn it down. It can be a revelation to some that feelings can be controlled in this way. This is a good technique if you feel angry, demoralized, anxious, out of control, or depressed. It can be useful for feelings associated with flashbacks or for ending a therapy session.

Other Containment Skills
These are additional steps that help you firmly control intrusive thoughts on a temporary basis, until you are ready to process them. Containment helps you function each day without being overwhelmed. It provides a way to tolerate intense feelings and choose when you wish to work on them. Containment also helps you to keep past separated from present.

• Split screen. This skill is like watching a television screen where two sports events appear at once. You divide a mental TV screen, putting the past on one side and the present on the other. You have remote controls that allow you to mute, slow down, shrink, fast forward, turn to black and white, or turn off the past. You download the difficult memories to a videotape as the therapist counts from one to three. You turn off the TV~ take out the tape, and store or file the tape in a safe place (wherever you want, maybe a safe with a special key). Place it there until you are ready to take it out.

• Freezing. Imagine that the intrusive thoughts, images, feelings, or recollections are ice cubes that you’ll store at your therapist’s office. Visualize a big scoop that scoops up the ice cubes and drops them into Tupperware containers. Tight-fitting lids on the containers seal in the ice cubes. See the containers safely stored in a freezer outside your therapist’s office. You and your therapist can retrieve the ice cubes, one container at a time, and use them in an appropriate way to help your therapy progress.

• Dirty laundry. Imagine the intrusive thoughts, images, feelings, or recollections as soiled clothing which needs to go to the laundry See yourself stuffing the soiled clothing in a laundry bag and calling the laundry service. Imagine that the laundry truck arrives. The laundry bag is placed in the laundry truck, the truck doors are closed, and you watch through a window as the laundry truck drives away. Watch the truck turn the corner and disappear. The laundry is next to your therapist’s office. You and your therapist can pick up your laundry together, sort it out, and use it in an appropriate way to help your therapy progress.

• Shrinking techniques. Imagine that you are looking at distressing material through a telescope in reverse, so that it becomes very small and far away. Or imagine that you are in a plane flying over the material and looking down. You are in control; you are the boss. You say how high and far away you wish to go.

• Other containment techniques. There is no one best way to do this. The best technique is the one that works for you. Create a strategy that you like to get better control of your symptoms. You might, for example, imagine the distressing material written on a chalkboard, then erased; written on a letter and mailed to a safe place; or packed in a suitcase and stored in a locker.
- Schiraldi PhD, Glenn R., “The Post-Traumatic Stress Disorder Sourcebook”, Lowell House: Los Angeles, 2000

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Personal Reflection Exercise #4
The preceding section contained information about intrusion management. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 10
What two skills are identified by Schiraldi to help defuse the distress of flashbacks? Record the letter of the correct answer the Answer Booklet.

 
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