SandySB

19/06/2016
by SandySB 6 Comments

Mindfulness: living in the moment

When you correct your mind everything else will fall into place.
Lao Tzu.

A few years ago I went through a difficult period with stress and depression. At this time my partner commissioned this brush painting for me. It shows a bamboo leaf falling, twisting in the air, full of life, while at the same time it is suspended in a single moment. A moment in which anything is possible, a moment that is full of possibility and in which nothing can be taken for granted.

It serves as a reminder that nothing lasts, that everything is transient, and that I need to do my best to stay in the present moment, open to new experiences and doing whatever I can to remain open to whatever opportunities and options come my way. It also reminds me that making predictions can be fraught with danger, after all a dragon might just fly down and eat the leaf.

This is also one of the reasons why I like rainbows, those fleeting, numinous phenomena that only exist in the eye of the beholder. A momentary experience of physics in action, something that is best when it is just experienced and enjoyed, not analysed.

This is what mindfulness is all about. Continue reading →

18/05/2016
by SandySB 2 Comments

Trauma Informed Care: Changing the culture to help the client.

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Some years ago a professor of oriental religion went to see a Zen master. “Please teach me about Zen,” he said. The Zen master was busy making tea, and when all was ready he started to pour the clear, steaming, green liquid into the professor’s cup. He poured til the cup was full, and then went on pouring, and the tea went all over the table, and onto the floor. “Stop!” said the professor, “The cup is full and there is no room for more tea.” “My precise point, ” said the master, “How can I teach you anything new when your head is already full.”

Zen story.

In the same way that different societies have their own ways of doing things, the habits and practices that make up the unique culture of that society, organisations also develop their own individual ways of coping with the work that they undertake. They too have their cultures, some of which are helpful to clients, some are neutral, while yet others are actually unhelpful.

All cultures are based on one simple idea, the idea that this is how we do things around here. Sometimes the mental models that a service holds at the centre of its treatment approach, and which underpin its entire philosophy of therapy, seem to work against the best interests of the group it was set up to help.

This may happen because the latest research has moved the story on, and the changed paradigm that has resulted has yet to trickle down, or sometimes such a state arises due to the aberrant beliefs, or long term practices of one or more charismatic staff, often seen as representing the culture holders of the organisation. Many of the worst abuses in social care homes seem to have resulted from this kind of situation.

Trauma Informed Care is one of these newer paradigms. A positive model that is being seen as a useful guide to inform the provision of services for those who have suffered developmental, attachment, or other complex traumas during their development. Such traumatic experiences interfere with the victims’ ability to regulate their emotions and automatic behavious, to form secure, reciprocal relationships and to think effectively when under stress. This represents a group of people who have very well-developed fight or flight responses, that have arisen through living in physically, or emotionally dangerous environments, at crucial stages of their development. People whose survival mechanisms continue to work too well.

When abuse occurs, the result is often hyperaroused people who show dramatic responses to what appear to the rest of us to be insignificant events. Neglect, on the other hand, can produce underaroused people who are less emotionally responsive than might otherwise have been expected. In either situation they show reactions to events that lie outside the norm for most people, and they can subsequently be seen as either uncaring or over-emotional, manipulative and attention seeking. They attract diagnostic labels such as Borderline or Antisocial Personality Disorder, which can all too easily becomes pejorative labels that prevent access to care, and not ones that should facilitate their help seeking behaviours.

One of the main problems for services and those who work in them is that, to some extent, they have to go through the same processes as their clients when they attempt to change how they work. Unlearning their current behaviours and the belief systems that underlie them, and then to replace them with new, more helpful way of understanding their clients’ difficulties. Like our clients the services have to learn to use this new vision to develop new ways of living in an altered world, ways that free them up and not ones that tie them down. We have first, to imagine that things can be different if we are to be able to work towards a more fruitful future.

For unlearning to occur, a participatory process is needed that enables a group to decide what is important to remember and what it is safe to forget. Sandra L Bloom

One of the key things here is to help the process of unlearning move forward. Giving up the hard-won knowledge (often over many years) about ourselves and our world, and then being able to start to challenge this world view and to replace it with something new, something fresh, something more helpful.

Moving away from a damage model to one based on the concept of the trauma organised brain, introduces a more fluid set of possibilities into the treatment interaction. We can move from the idea of “fixing” something, to the concept of using the construct of neuroplasticity to bring about a lasting transformation for our clients in a collaborative partnership. A process that requires us to develop new ways of thinking about and applying our hard-won skills to an altered therapeutic environment.

A recovery model demands that we reassess our assumptions about how we choose to define success.

We may be doing the same thing but thinking about it differently. No longer seeing ourselves as people who cure, but instead as facilitators, allowing the client to develop their own path to recovery within the therapeutic setting. A recovery model demands that we reassess our assumptions about what defines success.

There are advantages for both the client and the organisation in going through this process of thinking aobut how to change the way that we work together. The client comes up against a service that is more flexible, and better able to adjust to the changing nature of their presentation, often ins way that allow the right intervention to be offered to the client almost before it is needed. Services in their turn develop staff that are able to manage their client’s strong emotions more effectively, and without developing burning out to the same extent.

Trauma Informed Care also exposes us to the possibility of learning from vicarious resilience, the chance to witness, and then to learn from our client’s increased ability to bounce back from the vagaries of life in the twenty first century, as we help those in great distress to cope better with whatever life throws at them, and to live increasingly fulfilling and enjoyable lives.

If you are interested in these concepts I would be glad to hear your views and to read your comments.

I would also recommend the work of Sandra L Bloom and Brian Farragher, summarised in their trilogy of books on the Sanctuary Model.

Creating Sanctuary.

Destroying Sanctuary.

Restoring Sanctuary.

All published by Oxford University Press

10/04/2016
by SandySB 2 Comments

Trauma Informed Care: Dissociation for beginners.

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We use the terms trauma, crisis, major stressor and related terms as essentially synonymous expressions to describe circumstances that significantly challenge or invalidate important components of the individual’s assumptive world.

Calhoun and Tedeschi: The Foundations of Post Traumatic Growth

Dissociation is a symptom this commonly seen when a complex trauma pattern of brain functioning is present. It indicates an altered state of awareness. The narrowed field of consciousness that is present is often accompanied by amnesia.

Repression, on the other hand, occurs in a normal state of consciousness. This involves an active process of pushing memories, thoughts and emotions out of conscious awareness.

When our social environment is good enough during the period when we are developing, and growing up, then we are able to rapidly, and fluidly, change between the various emotional states that are needed if we are to respond appropriately to ever-changing environmental triggers.

When this developmental environment has not been good enough, we can become overwhelmed by the constant change in our emotional state and a protective state of dissociation can become a part of our emotional repertoire. Continue reading →

08/03/2016
by SandySB

Solution Focussed Thinking: some basic assumptions.

Janus: A God for doorways.

Insanity: doing the same thing over and over again and expecting a different result.

Albert Einstein.

Janus is the Roman God of new beginnings.

He is represented with two faces. Usually an old man looking back, full of past experience, and a young man, fresh faced and eager looking forward to the future.

Because he is the God of new beginnings, January when the old year gives way to the new, is named after him. Interestingly he is also the deity of doorways – places where we pass from the old to the new. Gateways to new opportunities.

This image of a new, younger person looking forward to the future, while holding their past experience in mind, is an apt one, and Janus would be a sound choice if the Greeks or Romans were looking for a suitable candidate to become the God of Solution Focussed Brief Therapy.

Solution Focussed Thinking is a process of looking forward to a preferred future, and at the same time, using past experience to highlight the strengths and skills we already possess. Skills that we can use to reach our own preferred future.

Solution Focussed Thinking is grounded in several basic assumptions.

Humans live their lives in a social context.

Human beings are most successful, and thrive best in the company of other people. We are described as being a social species. For this reason, solitary confinement makes an effective punishment or form of torture.

A small number of people find an isolated and solitary lifestyle to be enjoyable. Part of this ability comes down to a process of natural selection, which is especially useful in places like northern Scandinavia or Alaska, where it can be dark for up to six months of the year. The ability to survive in such an environment is due to the values and skills that the inhabitants of such inhospitable places pick up, and which come to be part of the culture. Those who can deal with this lifestyle – through a mix of genetics and culture – remain; while those who cannot tolerate this social and geographical isolation move away, thus ensuring an increased prevalence of the traits that permit humans to survive in such places.

However, even in very isolated places a strong sense of community persists, and provides the shared experience that gives a sense of belonging. The erosion of this sense of communality may make an active contribution to the current epidemic of depression that is sweeping across the western world.

Human society depends on language for effective functioning.

In this context the term language is used in its widest possible sense, and does not just refer to the words we choose to use. Human communication is complex, and the research suggests that the words we use provide only 7% of the meaning contained in any spoken communication.

When language is used to provide information, context is everything, and it is these differing contexts that explain why people from different cultures, even ones that seem to be very close in heritage, manage to misunderstand each other. Tone of voice, facial expression, the speed and rhythm of speech, the place and time where the words are heard, all help to convey the precise meaning of what is said. The fact that the person who is talking does so under duress, with a gun to their head, can also influence the message that we hear!

Language is so flexible that it possible to say something in such a way as to make words mean their exact opposite.

Everything is a story, a narrative, a sequence of events with characters communicating an emotional content. We only accept as true what can be narrated.

Andrea’s Corelli – The Angel’s Game.

Humans use language to construct their world.

We use language to give structure and substance to our world, and not just to describe it. The choice of the words that we use to describe events gives meaning to our lived experience, indeed the words that we use can change our view of the world completely.

One example could be seen during the bushfires in New South Wales a couple of years ago. The press asked a leading expert on Post Traumatic Stress Disorder how many children were likely to suffer post traumatic symptoms because of the fires. He gave a figure of about 8%.

This lead to a government and public outcry, and there was a rush to provide counselling and other interventions to all who might have been affected, at the cost of several million dollars. If the press had reported the corollary of the reported figures i.e. twelve out of every thirteen children would be fine, perhaps the government might have acted in a more sensible fashion.

I need to get another new iPhone.

It can be seen that the choice of words, and the emphasis given to what is said, has a significant impact on the listener. Politics and advertising are based on using words in this way, in an attempt to persuade others to a particular, partisan point of view, or to get some other message across. The intent is to persuade the audience to believe something that serves the politician’s or advertiser’s agenda. We end up voting out of some magnified misperception of risk, or suddenly find ourselves needing yet another new iPhone.

Everybody has their own individual way of using and choosing words, so it is vital to use the client’s own language when talking about things. If we share in the same language game, or at least try our hardest to do so, we put ourselves in the best position to ensure that what we talk about has meaning to our clients, and that this understanding will arise out of a shared understanding.

Thought also seems to use language, and provides a way for us to converse with ourselves; for the majority of us this involves the use of words in a kind of internal dialogue. The tone of these internal thoughts also has a dramatic effect on our world view. If we can use language to help change how people think about themselves, and the world that they inhabit, then they can begin to imagine the changes they want to accomplish, and so can bring them bout.

Language is a powerful tool for helping others.

A solution focussed approach uses language in a positive way, by encouraging the client to see the positives that already exist in their lives. The meaning of the words we hear is influenced by our state of mind, so that the current emotional experience of the listener plays a significant role in how they interpret what they hear.

This is a two-way street and words can also influence our state of mind. A process that is seen in the use of cognitive Behavioural Therapy.

“Words were originally magic.: – Sigmund Freud

When we are in negative or depressed mood states it is much easier to think even more negative and unhelpful thoughts, so if we are in an anxious state it is very easy to misconstrue innocent environmental cues to trigger our anxiety even more. Similarly, when we are in a positive state of mind it is easier to find more positives upon which to focus. It is interesting to see how being in love blinds us to all the negative traits in our partners!

Making a choice to concentrate our attention and focus on the positives in our lives can have major positive effects on our mood and relationships.

Competence and resourcefulness are the norm.

Human beings are basically competent and resilient, it is the events of our lives that leave us feeling powerless and incompetent. We all have strengths that we can mobilise to make the changes needed to improve the quality of our lives. However, it is often hard to recognise these for ourselves, especially when under stress or in a difficult situation. Looking for strengths, and providing evidence for their existence from the person’s past experience and behaviour can enable them to start to use these strengths and begin to steer life in a more satisfactory direction.

Focussing on strengths when we talk, can help to turn the conversation away from the temptation to judge or blame, instead it helps highlight the skills we have used to survive so far. No matter how bleak and awful an individual’s environment may appear there are still resources, however small, that can be mobilised.

To explore the past and uncover these resources requires a collaborative approach. It helps us to see ourselves for ourselves, and to have the last word in deciding what we need to do to change our lives.

Using language that is future focussed and which sets out to elicit what are genuine positives helps this process to evolve. Focussing on strengths, and emphasising positive explanations through reframing, helps to increase both a belief that change really is possible and to enhance the motivation to bring it about.

Solution talk is more helpful than problem talk.

A solution focussed conversation is future focussed, and concentrates on eliciting what is called the client’s preferred future, and in as much detail as possible. The world as it is when their difficulties have come under control.

Problem talk magnifies the impact of past problems and creates a perception of even more problems.

In a therapeutic setting this starts by using language that helps focus the client onto their future “problem free” state. A vision of a life that fits within their new world view.

How will you know that talking with me today has been helpful?
What will tell you that you no longer need to come?
What are your best hopes?
What will you be doing when you “have your life back”?

There is a deliberate and active choice to focus the client’s attention onto a realistic perception of positive future experience, helping them to uncover solutions to their difficulties that are based on their strengths, rather than getting bogged down in conversations about past problems to start concentrating on making changes to their lives that they can achieve.

Problem talk magnifies the impact of past problems and creates the perception of even more problems, helping to bury the client even further in a quagmire of chaos. Solution talk, on the other hand, brings the client’s focus onto positive experiences, highlighting the resources that have been helpful in their lives so far.

This helps us to create even more solution ideas.

“We take desperate people into small rooms, and talk them out of it. Michael Hoyt

When people talk about their problems we listen attentively. Rather than get bogged down in exploring their difficulties in detail we are more interested in what is revealed about their ability to cope. By avoiding the temptation to analyse problems we can help to convert negative, ruminative cycle into positive chains of thought.

The words that we choose to use in any conversation can alter the personal meaning of any experience, altering our perception of what happened. Even a slight change in emphasis has an impact on the outcome of events. Solution Focussed Thinking uses words to change other peoples’ worlds.

For this reason, we need to choose our words with great care.

25/02/2016
by SandySB 3 Comments

Trauma Informed Care: Trauma and the Brain.

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“The traumatic stress field has adopted the term “Complex Trauma” to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child’s caregiving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood.”

– Developmental Trauma Disorder”
― Bessel A. van der Kolk

People who have survived significant developmental trauma often show behaviours that seem to be counterproductive. They act in ways that can make their situation worse, and the degree of behavioural response seems, at times, to be unrelated to the the size of any triggering stimulus.

This is a direct result of the impact that developmental trauma can have on the developing brain, people who have such Trauma Organised Brains, may behave in ways that appear to make little sense to a rational observer. However, with the greater understanding that modern neuroscience is providing about brain functioning, such apparently irrational actions and damaging responses can be more clearly understood. Continue reading →

07/12/2015
by SandySB

Trauma Informed Care: Attachment trauma and neuroplasticity

Early experience shapes the structure and function of the brain. This reveals the fundamental way in which gene expression is determined by experience.
Daniel Siegel

Homo sapiens is a social species, and we have a prolonged developmental phase of dependency as we grow to adulthood.

Because of this, evolution has kitted us out with systems that enhance our ability to form relationships with others in our community.

Continue reading →

24/11/2015
by SandySB

Mindfulness and therapy: making space for thinking.

Sometimes a cigar, is just a cigar. Attributed to Sigmund Freud

Psychotherapy is a conversation. Albeit a highly specialised one that does not solely rely on words for meaning to be understood. The idea behind this exchange is to help the client, or patient, achieve a greater awareness of their inner life, and the impact that this has on their interaction with the world. When we understand the connections between our thoughts, emotions, and behaviour, we are in a better position to be able to change. Once we start to develop this kind of awareness, we can alter the way we live, and change our perceptions about our place in the world. Continue reading →

15/11/2015
by SandySB 3 Comments

Trauma: unlearning the past to regain the future.

Give me a child until he is seven, and I will give you the man.
St Francis Xavier paraphrasing Aristotle (with a certain sinister undertone).

Amongst all the great apes, Homo sapiens has an unusual gift. The ability to hear a sound and then to copy it. This skill arises from an innate drive to learn language, and to communicate. This is a hard wired aid to social living that has developed over millions of years of evolution.

This drive to learn is seen in the “babbling” phase that we all pass through as infants. We make repetitive sounds, as if practicing, before we start to speak words. This stage occurs in children of all language groups, all of whom make similar sounds; it is also present in those children who are born deaf.
Continue reading →

02/11/2015
by SandySB 4 Comments

Conscious attention: looking after our inner world.

If your mind carries a heavy burden of past, you will experience more of the same. The past perpetuates itself through lack of presence. The quality of your consciousness at this moment is what shapes the future. ― Eckhart Tolle

Our brains have a very narrow bandwidth for the conscious processing of information. This means that we spend a lot of time letting autopilot run our lives, based on how the unconscious mind processes incoming information. The unconscious processes information rapidly while the conscious mind is much slower. This has important consequences for our survival but can create difficulties in the modern world.

The unconscious mind is not able to tell the difference between what is real and what is imagined. The same pathways in the brain can be triggered by either of them. This means that we may respond to our internal thought processes or our current emotional tone, as if they were a response to real events in the outside world. Continue reading →

28/10/2015
by SandySB 1 Comment

Trauma informed care: an end to revolving door syndrome in mental health?

“I became what I am today at the age of twelve, on a frigid overcast day in the winter of 1975. I remember the precise moment, crouching behind a crumbling mud wall, peeking into the alley near the frozen creek. That was a long time ago, but it’s wrong what they say about the past, I’ve learned, about how you can bury it. Because the past claws its way out. Looking back now, I realize I have been peeking into that deserted alley for the last twenty-six years.”
― Khaled Hosseini, The Kite Runner

In my day-to-day working life I see many young people. Many of them have been given various mental illness diagnoses. While many of these are correct according to our “diagnostic” manuals, they add little to helping a young person find workable solutions to their dilemma.

As a Child and Adolescent Psychiatrist, I feel that my remit should lie in working to improve mental health and not just in treating mental “illness”. This is supported by the organisation for which I work.

The Recovery Model lies at the heart of its philosophy of care and is one of its guiding principles. This means that we should focus on helping young people, and their families, to enable the young person to lead the best possible life, no matter the nature, or degree of illness, or what sort of difficulties that they have.