TSR Training for Veterans

1. TSR Training for Veterans David A Fohrman, M.D.

2. What is TSR Training? • Traumatic Stress Resiliency (TSR) Training is a program to teach you how to avoid getting PTSD • Essential to Have • Easy to learn • Takes about 30 minutes

3. What is the Problem? • Veterans have a high risk for getting Post Traumatic Stress Disorder (PTSD) • Veterans also on active duty • In national guard or reserves • For example, approximately 30% of the OIF/OEF veterans have impaired due chronic PTSD symptoms • With each deployment, the number goes up • Veterans have a 90% of experiencing a non-military related traumatic event • These traumas can lead to PTSD • higher risk if already have PTSD, from combat or non-combat related experiences • had a traumatic brain injury (TBI)

4. What is the Problem? • PTSD symptoms (such as flashbacks, nightmares, chronically feeling jumpy, irritable, angry, anxious or depressed) cause serious problems • at work, home, in life • Lose job, marriage, friends, interests, life (suicide) • PTSD can be very difficult to treat • especially chronic PTSD (having PTSD symptoms for more then six months)

5. What is the Solution? • Prevent PTSD before it develops • Diagnosis of PTSD • Wait at least 30 days after traumatic/stressful situation ends • In case of a deployment, time closer to 3-6 months • If symptoms resolve prior to this window, will not get PTSD • If you already have PTSD from prior deployments/non combat related traumatic situations, TSR training can still help

6. TSR Training • Helps avoid road blocks that keep your body from naturally recovering from the effects of traumatic events. • Two parts • #1: What is PTSD • #2 What are the six road blocks to recovery and how can we avoid getting them

7. What is PTSD? • PTSD is biological problem • A disorder due to our brain’s creating abnormal trauma induced memories. • These memories cause you to experience almost all of the symptoms of the symptoms of PTSD • Intrusive recollections of trauma • Avoidance and numbing symptoms • Hypervigalence and hyperarousal symptoms

8. Biological reason for PTSD Symptoms

9. Body’s Memory System

10. What is PTSD? • PTSD is a spiritual problem • A disorder due to the creation of abnormal trauma induced faulty beliefs • Traumatic events can cause people to lose previously held core beliefs • Core beliefs are things you believe to be true but don’t think about • Examples are when I go through a green light other drivers will obey the traffic signal and stop • When I really need help, people I trust will help me out. • As a result of trauma, people can become lose their self confidence, not trust other people, become very cynical, think everything is ‘worthless or meaningless’ and/or may lose previously held religious beliefs

11. What is PTSD? • PTSD is a disorder due to a failure to naturally recover from the effects of trauma • All traumatized people temporality have some symptoms of PTSD • People get PTSD when they are unable to naturally recover • They don’t recover because trauma creates six road blocks to recovery • Soldiers have not been taught how to avoid these roadblocks.

12. Six Roadblocks to Recovery #1 – Can’t feel safe #2 – Can’t relax #3 – Emotionally isolate self #4 – Unable to stay in optimal zone for recovery #5 – Avoid talking about trauma #6 – Unable to fix trauma created faulty beliefs

13. Six Steps to Recovery • Use mnemonic: GROWTH • G – Go to a Safe place • R – Relax • O – Open Up • W – Wait until you are ready • T - Tell your story • H - Heal

14. GROWTH: Go to a Safe Place • Feelings safe means feeling both physically and psychologically safe • Physically safe – feel will not be unexpectedly hurt or killed • Psychologically safe – feel will not be taken advantage of while experiencing strong negative emotions

15. GROWTH: Go to a safe place • Examples, • At home • With friends • Doing an activity you enjoy • If you are doing something you enjoy, you feel safe • Can use handout to help you figure out what is a safe place for you

16. Roadblock #1: Don’t feel safe • Traumatic events can make us chronically feel unsafe • Like we might unexpectedly be in a life threatening situation • may sit with back against wall in restaurants • Avoid or really dislike crowds • For those that have never experienced this feeling • Like not having enough oxygen • Very hard to do anything other then try to feel safe

17. Avoid Roadblock #1: Don’t feel safe • Regain sense of safety after trauma. • Practice gradual exposure technique • When something makes us feel afraid one of two things happen • We freak out, panic, feel horrified, helpless, etc. • We stay in control; with time, anxiety will go away • Each time we stay in control will feel less and less anxious anxiety time

18. GROWTH: Relax • May think of one goal for relaxation: • ‘de-stress’ • Two Goals: • 1. contain excessive emotion • 2. regain a sense of being in control

19. Roadblock #2: Can’t relax • Traumatic events can make it hard to relax • Chronically activate fight or flight response • Feel anxious nervous, increase heart rate, blood pressure, dilate pupils • Can’t relax while fighting or running away! • Trauma are events where things are “out of control” • Can chronically feel this way

20. Avoid Roadblock #2: Can’t relax • Relax after trauma by having relaxation techniques that work for you • Can use breathing technique, described in handout • Use any other technique that works • Literally hundreds of books in library, book stores • Can use tapping technique to make flashbacks go away • Make sure you can feel in control “again” after trauma • Figure out what you enjoy doing • Hobby, sport, work, being a parent, • Do this in “easy way” after trauma to help you feel in control again. Can use relaxation techniques to help with prolonged exposure

21. GROWTH: Open up • Collectively, we can emotionally deal with what we can not deal with alone • True both in military and civilian settings • Enemies that are emotionally resilient are very difficult to beat • Examples are soldiers during war of Independence • True psychologically and biologically!

22. Roadblock #3: Emotionally Isolate Self • Traumatic events are situations were people close to us can be hurt or killed. • When this happens there is a natural tendency to emotionally pull back • For a limited period of time • Like having a rubber band snap on ones fingers • More cautious next time • Problem: people choose to constantly isolate self • minimize emotional contacts

23. Avoid Roadblock #3:Emotionally Isolate self • Use handout: Suggestions for Opening Up • First talk about Easy Topics • Then talk about more difficult topics • Talk about the what, where, when, how for each topic

24. GROWTH: Wait until you are ready • Wait until you are ready • You need to be in your “optimal zone for recovery” before continuing • If you are below your optimal zone – your brain will not process memories • This happens when you drink alcohol, use drugs or actively avoid thinking about the trauma • If you are above your optimal zone, you will not re-process your abnormal trauma induced memorieswhich will make it harder to fix them in the future

25. Avoid Roadblock #4: Can’t fix abnormal trauma memories • When your ready to recover, make you’re you are in your “optimal zone for natural recovery” • Some people are ready to start recovering a day or two after the event, others wait weeks or a couple of months • Use the handout: Optimal Zone for Recovery” to make sure your brain is biologically in the right place before you talk about the trauma with someone else. • Doing this will increase the speed in which your brain will fix it’s abnormal trauma induced memories

26. Optimal Zone for Recovery

27. Handout Your optimal Zone for Recovery

28. GROWTH: Tell your story • The best way to recover from the effects of trauma is to talk about it • Name for this: Natural Debriefing • Teaches you how to naturally debrief • Something we do often do after a stressful day • We talk to a spouse/significant other or a loved one • Talking doesn’t change ‘what happened” • Still, we feel better • In case of trauma • Talking also helps brain re-process trauma created abnormal memories • Easier said then done • We don’t practice talking about trauma • Trauma usually a rare event • Something people keep to themselves

29. Roadblock #5: Avoid Talking about trauma • Traumatic events bring up: • very strong emotions like horror, helplessness, intense fear, anger, shame, guilt • Thoughts, beliefs about ourselves, others or the world that are very distressing • “It was my fault” • “I can’t trust anyone because of what happened’ • Natural not to want to talk about, let alone think about, these things

30. Avoid Roadblock #5: Avoid talking about trauma • Practice by: • First thinking of something that bothers you • if have a hard time, think of a time when you “over reacted’ to something – for example, became angry for little or no reason • think about something that irritates you; bothers you only a little • write down, in outline form, what happened • use handout: Tell your story for an example • tell this story to someone else • if feel overwhelming emotion, stop • main thing is the process • does not matter how long you speak as long as you stay emotionally in control

31. Session #6: Heal Healing occurs when your past traumas no longer holds you back from living your live the fullest • Healing occurs in two ways: Biologically, Spiritually • Biologically • reprocess abnormal trauma induced memories • Spiritually • Fix any trauma induced faulty beliefs

32. Heal Biologically • Process abnormal trauma induced memories • Stop uncontrolled reactivation of event, flashbacks, etc. • Stop excessive fight or flight activation • Stop startle reaction, irritability, hypervigalence

33. Heal Biologically • Fill out the PTSD symptom checklist, any symptom you have more then ‘rarely’ is a positive response • If you have any positive response, use the GROWTH technique to help make these symptoms go away. • If you still have symptoms for more then two months after using these techniques, get additional help! • PTSD can be very difficult to treat!

34. Heal Spiritually • Trauma causes us to lose things important to us • Both concrete/specific and beliefs • This causes us to: • disconnect with ourselves • “live in your head” and become excessively stoic • disconnect with others • Emotionally as well as physically • disconnect with our beliefs/ideals • Start questions basic/or long held secular and/or religious beliefs

35. Heal – reconnect to yourself • Identify if you are disconnected • Difficulty experiencing/expressing intense emotions • Experience unexplained medical problems • Heal by being able to experience emotions without getting overwhelmed • By body sensations • Thoughts • Recover from unexplained/stress induced medical problems • Especially gastrointestinal, headaches, other unexplained aches and pains • Sexual dysfunction • Need to be able to express intimacy and aggression

36. Heal – reconnect to others • Identify if you are disconnected • Physically isolating oneself • Emotionally isolating oneself/avoiding emotional intimacy • Honestly/behavior will tell you if this is an issue • What would an ‘fly on the wall’ say you are doing • Often held back in emotionally reconnecting because of our trauma induced beliefs

37. Before being traumatized (1) I am in control of my life (2) I am competent. (3)I can reach my goals (4) What I think, feel, say and do effects other people (5)I can control how I spend my time (6) I am usually pretty healthy person After being traumatized (1)My life is out of control (2)I am basically incompetent. (3) I can’t accomplish what I set out to do (4)My actions, thoughts, and feelings do not affect any one but me (5) I can not take control of how I spend my time (6) I am usually sick Heal -reconnect to your beliefs Handout - Identify if you have trauma induced beliefs

38. Heal re-connect to your beliefs • Use questioning of beliefs as an opportunity to growth • Other cultures view trauma as a rite of passage • Opportunity to grow • Researchers have a name of this: Post Traumatic Growth • As a result of living through a potentially life threatening event, people often report they now • ‘try to live each day to the fullest’ • ‘do things (like hobbies, going on vacations, etc.) that they had put off doing before’ • ‘feel that their life is more meaningful’ • ‘are closer to their friends and family’ Pragmatically – emphasize decision to prioritize “connecting”

39. Change your actions, change your life • Use OIA acronym. • Observe • Imagine • Act • Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to • examples: spouse tries to talk to you, you pretend not to hear him/her • first identify situation retrospectively, then Use OIA acronym. • Observe • Imagine • Act • Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to • examples: spouse tries to talk to you, you pretend not to hear him/her • first identify situation retrospectively, then

40. Imagine • Imagine – how you would act if you wanted to emotionally connect • example – spouse talks to you, you listen • Use active listening skills • We all have them, but don’t always use them • Identify at what stage of moral development client is – speak to them at that level • Practice scenarios that could happen

41. Act • Act as if you want to emotionally and physically connect • This may or may not be connected to your current beliefs • May be an ‘act of faith’ • Faith means different things • This is secular • Refers to acting in a way you hope (or wish) were true even though you may not belief it’s true • Act first, and your beliefs will follow

42. Final points • Trauma happens! • PTSD and other long term post trauma problems don’t have too • Can use GROWTH to help you and your loved ones recovery from the psychological effects of deployment. • G - Go to a safe place • R - Relax • O - Open up • W -Wait until you are ready • T - Tell your story • H - Heal