1. Anita S. Treloar, Ph.D. April 29, 2011 4/29/20111 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

2. Presentation Objectives Participants will understand the basic theoretical basis for Seeking Safety and Acceptance and Commitment Therapy (ACT) groups for adult trauma survivors. Participants will learn the basic structure of Seeking Safety Groups. Participants will learn the structure and content of one example of an ACT group which can be provided for trauma survivors. 4/29/20112 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

3. Credits Information on Seeking Safety Treatment and Acceptance and Commitment Therapy is derived from resources noted in Resource List. 4/29/2011 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)3

4. Post-traumatic Stress Disorder (PTSD) Person exposed to traumatic event that Involved actual or threat of death or injury Involved experience of intense fear, helplessness, or horror Traumatic event is persistently reexperienced Persistent avoidance and numbing Persistent symptoms of increased arousal 4/29/20114 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

5. Co-occurrence of PTSD and Substance Abuse High co-occurrence of PTSD and Substance Abuse PTSD can elicit substance abuse (e.g., for coping), which can make client more vulnerable to further trauma Recovery from substance use can trigger PTSD or memories the substance had been blunting Therapy re. PTSD can trigger substance abuse to cope with memories Therefore best to treat them together (e.g., Seeking Safety approach) 4/29/20115 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

6. Stages of Healing from PTSD and Substance Abuse* 1. Safety: Goals – Free self from substance abuse Stay alive Build healthy relationships Gain control over own feelings Learn to cope with day-to-day problems Protect self from destructive people and situations Not hurt self or other Increase functioning Attain stability *From Seeking Safety p. 101, derived in part from Herman, 1992. 4/29/20116 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

7. Stages of Healing from PTSD and Substance Abuse (continued)* 2. Mourning the past: losses and pain experienced. 3. Reconnection with the world in joyful ways: thriving, enjoying life, able to work and relate well to others. *From Seeking Safety p. 101, derived in part from Herman, 1992. 4/29/20117 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

8. Theoretical Considerations: Learning Curve Individuals learn best at moderate levels of challenge. Too low challenge: boredom, inattention Too high challenge: overload, shut down Moderate challenge: optimal learning 4/29/20118 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

9. Theoretical Considerations: Therapeutic Pacing Pace therapeutic challenge for clients’ moderate range. “Building emotional muscle.” Building ego strength, client’s “observing ego.” 4/29/20119 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

10. Theoretical Considerations: Session Cognitive-Affective Curve Generally: start with cognitive, move to affective work, end with cognitive. Don’t go deeper than the client can contain. 4/29/201110 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

11. Advantages of Group Treatment of Trauma Survivors Reduces stigma and feeling of isolation; they know they are not alone Clients can learn from each other’s experiences Mutual support is empowering 4/29/201111 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

12. Challenges to Group Treatment of Trauma Survivors Contagion of trauma stories/pain can trigger memories or “flooding” One client’s trauma can “hijack” a group session Boundary problems can create rescuer, victim, persecutor roles, etc. 4/29/201112 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

13. Seeking Safety Treatment Approach Considered an evidence based best practice Can be used individually or in groups Focus on Safety Stage of Healing Mourning work may take place in parallel individual sessions. During mourning work, participants may often need to return to safety stage. 4/29/201113 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

14. Seeking Safety Content Four content areas: cognitive, behavioral, interpersonal, and case management Structured format of each session Present- and problem-oriented to reduce symptoms Psycho-educational Affective components are contained in a cognitive structure. 4/29/201114 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

15. Seeking Safety Topics Examples: Safety PTSD: Taking Back Your Power Detaching from Emotional Pain (Grounding) When Substances Control You Taking Good Care of Yourself Integrating the Split Self Recovery Thinking Healthy Relationships 4/29/201115 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

16. Seeking Safety Group Description Women’s Seeking Safety Group First Nations Community HealthSource What is the Women’s Seeking Safety Group Approach? The Women’s Seeking Safety Group is for women who have experienced trauma and related issues such as substance abuse and domestic violence, and are seeking a safer, healthier life. Sessions will include both information and the opportunity to share. Participants are usually also involved in individual counseling. Is this group right for me? This group may be right for you if: You are experiencing consequences of unhealthy choices in your life. You have experienced a traumatic event or events. You have difficulty maintaining positive, safe relationships. Memories or feelings about the traumatic event make it hard to stay clean and sober, or to make healthy choices. Focus on safety The #1 goal of these sessions is to help you be safe. “Safety” includes the ability to: Manage trauma symptoms (such as flashbacks, nightmares and negative feelings) Cope with life without using substances Take good care of yourself Find safe people who can be supportive of you Free yourself from domestic violence or other abusive relationships Prevent self-destructive acts (such as cutting, suicidal thoughts, unsafe sex) Find ways to feel good about yourself and enjoy life. How can I join this group? Individuals interested in joining this group may contact Anita Treloar at 262-6586 or the Behavioral Health receptionist at 262-6520. Membership is open to clients involved in individual therapy through FNCH Behavioral Health services. Sessions will be Wednesdays from 4:00-5:30 p.m. New members may join by coming at 3:30 p.m. on their first Wednesday to meet with Anita for group orientation. 4/29/201116 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

17. Seeking Safety Treatment Agreement Includes safety, honesty, confidentiality Group treatment agreement includes Not discussing details of trauma or substance use Contact with members outside sessions is discouraged 4/29/201117 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

18. Seeking Safety Group Structure Check-in: How are you feeling? What good coping have you done? Any substance use or other unsafe behavior? Did you complete your commitment? Community resource update? The quotation (with discussion) Session topic: readings and discussion related to participants’ lives Check-out One thing got out of today’s session New commitment What community resource will you call? 4/29/201118 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

19. Seeking Safety Approach Questions; Discussion 4/29/2011 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)19

20. Acceptance and Commitment Therapy (ACT)*: Core Concepts Mindfulness: being in the present Acceptance (not the same as agreement) Commitment to valued action *Steven Hayes; see Resource List 4/29/201120 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

21. Goals of ACT Psychological flexibility (see pre- post-assessment tool) Requires facing pain that individual may have been avoiding: this confronts the avoidance strategy of PTSD 4/29/201121 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

22. Clients Most Appropriate for ACT Group* Preferably clients have demonstrated ability to keep themselves safe. Some may have completed Seeking Safety Group. Ability and willingness to use a complex cognitive approach. Especially helpful with clients who have felt stuck in their progress and want to move forward in their lives. *Note: Group is developed from resources noted in Resource List 4/29/201122 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

23. ACT Group Acceptance and Commitment Therapy (ACT) Helps individuals to: Accept Your Reactions and Be Present Choose a Valued Direction Take Action This approach is helpful for those experiencing: Depression, anxiety, substance abuse, post-traumatic stress, chronic pain, medical issues, and stress. New twelve week cohort for men and women will start December 3, 2010 at 2:00 p.m. at FNCH Behavioral Health Services, and will meet Fridays from 2:00-3:30. The group is open to FNCH BH clients with assigned individual therapists. Come join us! For information, contact Anita Treloar at 262-6520. 4/29/201123 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

24. ACT Group Topics* 1. Introduction: ground rules, introduction, pre-test 2. Avoidance and Control; Pain and Suffering 3. Pain and Suffering (continued) 4. Acceptance and Willingness 5. Passengers on the Bus 6. Defusion: Handling the Passengers 7. Defusion (continued) 8. Who Am I? 9. Values #1 10. Values (continued) 11. Committed Action 12. Graduation *Developed from materials in Resource List by Anita Treloar. 4/29/201124 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

25. ACT Group Format: 12 week cohort model Check in (thoughts and feelings since last session; application of last sessions material) Information Application through discussion and/or written material Check out (what learned, reactions, application to the week ahead) Mindfulness exercise (ground in present) 4/29/201125 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

26. ACT Group Comments Discussion 4/29/201126 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

27. Resource List Follette, V.M. & Pistorello, J. (2007). Finding life beyond trauma: Using Acceptance and Commitment Therapy to heal from Post-traumatic Stress and trauma-related problems. Oakland, CA: New Harbinger. Hayes, S.C. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S.C. (2005). Get out of your mind and into your life. Oakland, CA: New Harbinger. Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books. Najavits, L.M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. 4/29/201127 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)

28. Resource List (continued) First Nations Community HealthSource, Behavioral Health Services, 5608 Zuni Rd. SE, Albuquerque, NM 87108, 505-262-6520. anita.treloar@ihs.gov 4/29/201128 Therapeutic Groups With Adult Trauma Survivors - Anita Treloar (copyright)