Moral Injury

@livehappycounselling

Moral injury is rooted in a violation of personal values. It’s an important concept but it is one that many people haven’t heard of. It refers to the extremely distressing psychological, behavioural, cognitive, and spiritual aftermath of exposure to events that violate our sense of ‘what’s right’. Regardless of if these morally injurious events were through commission, omission, or betrayal, the lingering consequences on a person’s sense of self are tremendous.

Main Points:

  • Moral Injury is a loss-injury, creating a wounding to our identity, a fracturing of our sense of self, and altering our core beliefs
  • Moral injury shares many of the same symptoms as PTSD and carries with it a suffocating sense of shame, guilt, and anger
  • It is possible to experience PTSD without moral injury
  • Left untreated, moral injury can lead to PTSD, depression, and suicidality
  • Public Safety Personnel are exposed to severe moral stressors during the regular course of their work and are at high risk of experiencing a morally injurious event
  • If a person from this occupation experiences PTSD and is in therapy and isn’t experiencing a reduction in symptoms, it could be that a moral injury is driving the ongoing symptomology
  • To start healing moral injury, we have to start talking about it with someone who can empathetically listen
  • We have to speak our truth about the violation, the shame and guilt, the impacts to our sense of self, isolation from others and alienation from spirituality/beliefs
  • We then move beyond moral injury to forgiveness of self, shame resilience, and a re-alignment with our values and belief systems

Introducing the Concept: Moral Injury

The term Moral injury was first coined by psychiatrist Dr. Jonathan Shay (1991), who saw the symptom first among the military veterans he was working with and who described it as the physical, social, and psychological results of a betrayal of what’s right. Moral injury is a loss-injury, a fracturing of one’s sense of self, and a disruption in trust (of self and others) that occurs within one’s moral structure. Any events, actions, or inaction transgressing one’s moral and ethical beliefs, expectations, and standards set the stage for moral injury. A betrayal on a personal or organizational level can act as a precipitant.

@livehappycounselling

The Link Between Moral Injury and Post-Traumatic Stress (PTSD)

Moral injury is separate from PTSD, and there is presently no diagnostic category for moral injury. A moral injury doesn’t mean that a person fits the criteria for post-traumatic stress, a PTSD can be present without a moral injury. There are similarities in symptoms between moral injury and PTSD. When a moral injury is present with PTSD, the diagnosis of PTSD does not sufficiently capture moral injury or the shame, guilt, and self-handicapping/sabotaging behaviours that often accompany a moral injury.

In cases where a person does experience both PTSD and moral injury, the moral injury layer often goes unidentified. Opening up dialogue about moral injury and recognizing the signs can help improve treatment outcomes.

Moral Injury and Public Service Personnel

Journalist David Wood writes that “moral injury is the signature wound of today’s veterans”. So what is it about this population and all first responder/Public Service Personnel that puts them at greater risk of experiencing a morally injurious event?

During training, military personnel and first responders learn to function under the philosophy that the mission is more important than their personal comfort. They learn to compartmentalize for the sake of adapting and overcoming the challenges of performing their duty effectively.  In other words, they learn to ignore their inner experiences. While this enables them to efficiently carry out the duties of their job, there is a splitting off, or a separation of their human experience as a means of avoiding the mental discomfort and anxiety caused by traumatic witness, conflicting values, cognitions, emotions, and beliefs within themselves. There is utility to this: allowing one’s inner experience opens the flood gate for doubt, anxiety, or fear to bubble up to the surface which could lead to a sense of vulnerability – and in their job they must elude a sense of invincibility and power. Everything these individuals do in training is about shutting out the inner emotional experience in order for the mission to remain the primary focus.

Essentially, these individuals learn to override their natural stress response in order to complete work-related tasks, which is referred to as function over feeling. For many military and first responders, their profession becomes the prominent feature of their identity, with the suppression of the emotional side becoming entrenched. This, combined with the constant exposure to potentially morally injurious events regularly as part of their job put these individuals at higher risk of developing a moral injury. Moral injury creates an important cognitive dissonance between one’smorals and actions, resulting in a wide range of symptoms.

Symptoms of a Moral Injury:

The core symptoms of a moral injury include:

  • Chronic sense of guilt
  • Chronic sense of shame, including self-deprication and loss of self-worth
  • Spiritual crisis, including loss of meaning, spiritual conflict, questioning morality (including losing touch with their own moral reasoning), and changes to worldview
  • Trust Issues, including loss of trust in others and self
  • Re-experiencing (including intrusive thoughts, imagery, etc.)
  • Avoidance of reminders of the morally injurious event
  • Depression
  • Anxiety
  • Self-harm and suicidality
  • Substance misuse
  • Impairment in social functioning, including feeling disconnected and alienated from others, and withdrawing/isolating from friends and family

Moral Injury and Help-Seeking Behaviour:

Because shame sits front and centre in a moral injury, the injury itself may act as a barrier to accessing help and recovery. These individuals often feel ashamed, guilty or angry which can make them very reluctant to talk about their difficulties. And because it remains unspoken, they are unable to process and make sense of the internal moral conflict.

The Experience of Shame:
Shame is a fear-based internal feeling state. It brings with it a painful, intense and fundamental sense of inadequacy, worthlessness, and lack of belonging. More than a sense of “I made a mistake, I did something bad”, which is guilt, shame screams throughout every fiber of one’s being “I am a mistake, I am bad”. Shame can create extreme self-consciousness, a feeling as though not only are they less than, but that everyone can see it. Shame can erode one’s sense of self and become the lens through which they view themself. And because it feels so painful, we tend to fight furousionsly to suppress it and stay quiet about our experience of shame. And with anything uncomfortable, our unconscious defense mechanisms can be activated. As you can imagine, for those living with a moral injury, the majority of their time and energy is consumed with symptom management and not living.

The defense mechanisms we employ to escape from shame can come to take on a life of their own – our very own internal puppet master constantly directing our behaviour and reactions. Brené Brown describes these as ‘shame shields’. A person may have a pattern of moving away (withdrawing, secrecy), moving towards (seeking to always please and appease), or moving against (confronting shame with shame, attempting to have power over others, using aggression).

Developing Shame Resiliency:

There is another option though: in the face of shame it is possible to courageously voice it. Shame resilience refers the ability to recognize shame when it flares up and move through it in a constructive way, one that allows a person to align with their allies through communicating the experience, thus maintain their authenticity and reducing the pain of shame.

A central part of developing shame resilience involves empathy. Empathy refers to the ability to view the world the way another person views it, without judgment – recognizing their emotional experience through their lens. Empathy communicates to another person that they are understood, and that they are not alone. Whereas shame convinces us we are alone, empathy communicates the opposite. In this way, empathy becomes an antidote to shame.

In addition to learning to connect with empathy and seeking a listener who is empathetic, there are additional things we can do to develop resiliency to shame. Here are 4 additional ideas:

  1. Awareness: When individuals feel overwhelmed, it’s easily to slip into zoning out behaviours. However, this can entrench a habit of disconnection with self and gets in the way of a deeper level of self-awareness and growth. See step 3 below of overwhelm is problematic for you. Then, know the social/cultural expectations around shame in your workplace, home environment, extended family relationships, community, etc. And, start to become familiar with your typical pattern of reacting to shame: what shame shield do you tend to employ and in what situations is it activated? Working with a Counsellor that you feel a therapeutic fit with can assist you in working through the layers of shame resulting from a moral injury or those layers originating from earlier life experiences. 
  2. Recognize:  Recognize shame when it arises. This involves know what it feels like in the body (the felt sensation of shame), and the thoughts that go along side it. Shame often is first felt in the body, so being able to recognize the earliest felt indicator of it can alert you that action is needed.
  3. Ground yourself: Becuse the experience of shame can be so destabilizing, once you’ve recognized it, take a moment to get grounded. Try a deep breathing strategy, or any other emotion regulation strategy to return to your window of tolerance.
  4. Connect: Talk it through. Remember that shame thrives in silence, secrecy, and judgment. Prevent this by sharing the experience with someone you trust – someone who can listen empathetically. Shame is only effective when it convinces us that we are the only one and we are completely alone. The less we talk about shame, the more we have it.

Healing Moral Injury:

If the course of their training teaches Public Service Personnel to separate the two sides of themselves (the person who is on the job, and the person in all other domains of their life), then healing must involve working collaboratively with these two parts in order to resolve the moral injury, to resolve the inner conflict. It involves reconciling both parts of self: the stoic part and the empathetic part. And this starts with sharing it: communicating the trauma and the moral injury that occurred with someone who gets it. The listener has to have an understanding of moral injury because the shame and anger can run so deep alongside the injury.

A counsellor trained in trauma work, including the impacts of post-traumatic stress and moral injury, can work with an individual to recognize and heal:

  • the unique moral injury experienced and the internal conflicts
  • the layers of guilt and shame
  • the blocking beliefs that may be preventing resolution
  • the layers of unresolved grief that may also be present in the moral injury
  • weather or not there are underlying layers of moral injury (for example, childhood vs. adult onset)

To foster an environment that supports individuals in healing a moral injury, we must start up opening up the dialogue around moral injury and shame. Learn more what a moral injury is, and start talking about it. Notice when shame flares up in daily life, and talk about it with someone who can empathetically hold your story.

** This article is based on the presentation I made to the participants attending the Dr. G. Davidson Operational Stress Recovery Program in Vernon, BC. Please click the link to learn more about operational stress recovery and the programs offered at their clinic.

Check out the links below to learn more about moral injury.

Regulating Emotion: A Simple Check-in

He probably wasn’t referring to regulating emotion when Ice Cube wrote the lyrics “Check yo self before you wreck yo self”, but the lyrics are catchy and they pertain perfectly to emotional awareness! Read on to learn a simple strategy you can use to gain insight into the early indications that emotion is activating up so that you can utilize a coping strategy to return to the present moment.

Regulating emotion means we are better able to shift out of high emotion before it becomes distressing and painful, thereby rendering unhealthy coping behaviours unnecessary. To regulate emotion, we need to first recognize how we experience emotion in the body. This serves two important purposes:

  1. Awareness of emotion activating up in the body enables us to intervene with a healthy coping strategy before it reaches a distressing level, and
  2. Developing awareness of the sensations of calm can enable us to grow and deepen them.

It is also incredibly empowering because you will have created that internal sense of calm. One of the goals of learning to regulate emotion is to render all those unhealthy coping strategies unnecessary.

@livehappycounselling

Checking In Using the Subjective Units of Distress Scale (SUDS)

While this might sound complicated, it’s actually super easy to use and apply. The Subjective Units of Distress Scale (SUDS for short), is a 1 to 10 rating scale. It is used widely in counselling psychology to measure the level of emotional distress a person is experiencing at a given moment. It is ‘subjective’ because you make the rating for yourself. Using the SUDS scale, 0 refers to no distress, and 10 refers to extreme distress.

Try checking in to rate your SUDS once or twice throughout each day. It’s useful because often we miss the early signs of emotional activation and it only catches our attention when our present moment coping is completely derailed. If we can intervene at the early stages of activation, and engage in a calming activity, we will experience a lot less distress.

Five Simple Steps for Checking-in

Use this simple method for checking the SUDS:

  1. Look at the SUDS rating scale, and ask yourself “What’s my number?”
  2. Notice what sensations are present in your body (the felt sense of emotion)
  3. Notice what emotions are present?
  4. Notice the thoughts that go with that
  5. Then, if your number is between 0-3, take a deep breath and carry on with your day. Or, if your number is 4 or higher, use a coping strategy to shift emotion.

The early signals of the body shifting into activation can be subtle at times. Because of this, we can often miss the vital cues our body is giving off that indicate we are escalating into distress.

Learning to recognize the earliest sign that we are activating up can help us intervene sooner, and thus reduce that distress before it feels out of control. Developing awareness of distress lessening based on something you are in charge of directing is a remarkable achievement worth noticing!

Using the SUDS in Daily Life

When we live with chronic anxiety, a certain level of physiological activation comes to be part of daily life. When a troubling situation arises or when we are triggered, we spike up into high activation super fast because we were already in physiological activation.

If this sounds like you, getting into the habit of checking your SUDS several times throughout each day is going to be very powerful. You will likely catch yourself with clenched muscles, tight shoulders, and restricted breathing (to name just a few). Each time you check your SUDS and notice your body activated, use a coping strategy to help it settle.

Know When to Get Help

Emotion regulation strategies are useful for reducing distress at a SUDS of 7 and lower. If you rate your SUDS and notice you are feeling at a 7 or higher, please turn to your support system. Who can you call, where can you go, and what can you do? In these moments of distress, often the best and most useful thing we can do is have someone sit with us during the rain while we wait out the storm. Please don’t go this journey alone.

Insert Self-Compassion Here…

Learning to check in and shift out of emotional flooding is going to require an element of self-compassion. This means giving yourself the same kindness you would give to someone you care about. You need and deserve kindness and patience from you toward you.

If numbing or shutting down has been your go-to coping strategy in the past, you may find tuning in to be a little challenging. Please monitor your learning and your journey, and reach out to a counselling professional as needed.

Want more strategies like these? Check out my book Calm in the Storm: A Collection of Simple Strategies You Can Use Right Now to Shift Out of Anxiety.

Free pdf download of Checking In:

Want more strategies like these? Check out my book Calm in the Storm: A Collection of Simple Strategies You Can Use Right Now to Shift Out of Anxiety.

Anchor out of Flashbacks

If you have experienced a trauma and are struggling to cope with flashbacks and intrusive imagery/thoughts, please consider working with a Counsellor. In the meantime, try this to help reduce the intensity of the imagery and return to the present moment.

Note: this whole 5 step process can be done in a few minutes. Take some time to practice it in a moment of calm, so that you will have practice anchoring back to the present moment should a flashback intrude upon your day.

Acknowledge

The images, thoughts, memories, and physiological sensations that accompany a flashback can make you feel as though the trauma is happening right now. Acknowledge you are experiencing a flashback with kindness (i.e. “There I go again, this is a flashback”). Although this sounds simple, the natural tendency is often to push intrusive images out of awareness. However, suppression and denial just cause the imagery to come back stronger and more frequently. Acknowledge the flashback, and notice the emotions, thoughts, and physiological sensations that go along with it.

Even though I’ve listed using a mantra farther down in this article, often it can be helpful to use it when you acknowledge the flashback, because it helps establish that the trauma has passed – “It’s over”. And, the mantra can be repeated during the next step: slowing and following the breath.

Breathe

Take a deep, full breath in through your nose – one that you feel right into your abdomen – and exhale through your mouth.

When we feel out of control, our breathing also tends to be out of control. The experience of a flashback can cause emotional flooding, and can immediately trigger a change in our breathing: this might look like extremely rapid, shallow breathing, or breath holding. Both of these can lead to a shortness of breath feeling and can cause light-headedness, numbness or tingling in the hands or feet, dizziness, chest pain, and difficulty putting thoughts into words. These symptoms will exacerbate fear and anxiety, and can escalate a person into distress and panic. The breathing pattern itself can even come to trigger anxiety (for those who experience anxiety). In essence, they become caught in a cycle where anxiety brings on shallow breathing, and shallow breathing brings on anxiety. That is why slowing and deepening the breath is the very crucial second step here.

Rapid breathing and breath holding can amp the body up into a state of activation – but this capacity also means that we can harness the breath to shift the body into a settled place of calm. It is by slowing and deepening the breath that we learn to help our body out of activation. In fact, it’s one of the fastest ways to shift out of nervous system activation.

Try one of these tips if you are new to focusing on your breath:

  1. Focus on one deep full breath in through your nose, and exhale out of your mouth.
  2. Place one hand on your chest and one hand on your abdomen, to follow the in and out breath.
  3. Count to 4 as you inhale, pause for 1, count to 4 as you exhale, pause for 1, repeat

Anchor with your Senses

Your senses are an excellent way to ground you back into the present moment. Some examples include:

  1. Shuffle your feet, noticing your connection to the ground
  2. Move around the room,
  3. Get a glass of water,
  4. Wash your hands
  5. Choose a colour and count how many times you can spot it as you look around
  6. Listen to a favourite song

There are also more formal grounding strategies, such as 5-4-3-2-1. Some people have found a few exercises to be helpful, or even an invigorating yoga pose.

Use a Mantra

Mantras are statements we repeat to ourselves and which can have quite the potential to impact our attention, outlook, and mood. The sound or words of a mantra are simple and don’t demand a lot of effort. A mantra can be said aloud or silently, and is often most powerful when the words have meaning to you. It’s kind of like a tool for attuning your body and mind. A mantra can be used to increase our level of awareness and provide us with strength and focus, and even give us a sense of mental stability.

What mantra would you like to try? Above we looked at “It’s over, in this moment I am safe”. Some additional ideas include:

  • Safe and present
  • Right here, Right now
  • Just this one moment

Practice Letting it Go

In counselling, a safe space is created and emotion regulation skills are developed to assist you in healing from traumatic experiences. When you are alone, having the tools to move through a flashback and return to the present moment is essential. The final step in this coping process is to visualize letting it go. It won’t serve you to think further about the flashback, and may be even more distressing. You have acknowledged it, and by doing so you have recognized that a memory is still distressing. Work through it with a mental health professional. In this moment, practice visualizing letting it go.

To do so, as you exhale, imagine exhaling the whole flashback into a balloon. As you exhale, the balloon inflates. Then you imagine tying it off, keeping the memory safely inside the balloon. Picture extending your arm and releasing the balloon, to be taken away on the wind to be kept safe until you are supported in working through the trauma.

Every time the flashback comes back, use this strategy. Inhale deeply, exhale the traumatic memory into the balloon, tie it off, lease it for safe keeping.

Thank you for reading, and I hope you find this strategy useful. Focusing awareness using this 5 step anchor can shift thoughts away from flashbacks, racing thoughts, and obsessive thinking, and can bring awareness back into the present moment.

For more tips on shifting out of a flashback, check out Calm in the Storm: A Collection of Simple Strategies You Can Use Right Now to Shift Out of Anxiety

Lovers to Strangers

What’s cooler than seeing your book for sale on a bookstore shelf? Seeing it appear in a movie! Check out this short film by the very talented Director Chris Di Staulo: Lovers to Strangers, on Vimeo

Chris’ latest short film brings attention to the concept of love bombing.

New relationships can feel intoxicating at the beginning. You want to spend all your time with the person, getting to know them and enjoying their company. You still live your life as you normally would, while nurturing the new relationship and getting a sense of how this new love interest fits into your world. Healthy romantic relationships have a solid foundation of friendship (respect, trust, and kindness). 

Love bombing from a new dating partner can be hard to spot at first. It’s a manipulation tactic disguised as intense affection, charm, and desire. It’s used to gain your trust and love and leave you feeling as though you owe them something. Here are some tactics of love bombing to look out for:

  • Constant and intense compliments and praise and charm
  • Being showered with lavish gifts
  • Saying “I love you” very soon after meeting
  • Stating you are soul mates, that you are the only person who has ever understood them
  • Wanting commitment after only a few days or weeks of meeting
  • Constant phone calls and texts, to the point that you have little time to yourself
  • Demands a lot of your time, where you find yourself constantly changing your plans to meet their requests
  • Wants your full attention, and get angry or passive aggressive if you spend time on activities that doesn’t include them
  • Reacts with anger or passive aggressive behaviour when you implement healthy boundaries

A healthy relationship is built on trust, and that takes time to develop. There is kindness and patience, and your needs are respected similarly as you respect theirs. Listen to your intuition and go slowly in new relationships. Don’t lose sight of you, your interests, and your support network. If a new relationship feels as though it is moving too fast, and you are being made to feel guilty or are met with anger for wanting to slow down, there may be a manipulation tactic like love bombing going on. Turn to your support network, or reach out for help from a mental health professional. 

And in the meantime, please enjoy Chris Di Staulo’s short film, Lovers to Strangers – with a special cameo appearance from my book, Calm in the Storm, A Collection of Simple Strategies You Can Use Right Now to Shift Out of Anxiety.

Learn more about Calm in the Storm, A Collection of Simple Strategies You Can Use Right Now to Shift Out of Anxiety, at the following retailers:

Four Steps to Anchor out of Stuck Thinking and Deepen Self-Compassion

How often does the strong pull of anxious thinking lure you into its’ loop of incessant worry, what-ifs, and not-good-enoughs? Spending time on the thoughts that worry and anxiety drive you to think about isn’t the best the way out of it. In fact, thinking the thoughts that accompany anxiety often breeds more anxiety. We need a way out of those thoughts. One that calms our body and our mind, so that we can more accurately and compassionately deal with the experience. The RAIN meditation by Tara Brach offers just that. 

The RAIN meditation is an excellent way to steer out of anxious thinking cycles, deepen compassion and connection to self, and anchor back into the present moment. Take a moment and play with these 4 steps, to build self-compassion and step out of stuck thinking.

Recognize: Recognize the thoughts you are thinking, and name the emotion you are feeling.

Allow: Allow and accept the moment, just as it is. This emotion and experience doesn’t define you, and it will pass.

Investigate: Investigate with gentle curiousity, the felt sense of emotion. Scan your body, and notice what sensations in your body go with those emotions. Is there a negative belief linked with those sensations? Notice those thoughts and sensations with compassion for self. 

Nurture: Let your hand rest over your heart, allowing the experience to pass the way clouds pass after a storm. Notice what you need, soften your heart, and give yourself the kind words you’d offer a trusted friend.

Notice what happens when you allow emotion to be there, without suppression and without denial. When you let emotion be there, with gentle curiousity and the knowledge that it will pass, notice what starts to shift. Using this technique works because it interrupts our habitual way of responding to strong emotion and negative cognitions. With practice, the RAIN meditation can help you develop a new way to be with emotion, one that offers an exit strategy from stuck thinking and an anchor back to the present moment. 

Check out the full meditation by Tara Brach at: https://www.tarabrach.com/rain/

Be Kind, Especially During a Pandemic

This is my public service announcement about kindness during COVID. Also known as ‘don’t be a dick’.

As I write this, we are 9 months into COVID-19. We’ve been isolated and distanced, and now we’re amping up to distance and isolate some more. The rules are constantly changing – and they are new, and nothing like what they were pre-March 2020. And yes, it sucks. And when things suck, it can make us all a little grumpy. 

Please remember, no matter where you are, no matter who you are – we are in this together.

If someone forgets to sanitize their hands when entering a store or enters without donning their mask – a kind reminder is all it takes. And if they can’t don a mask due to medical reasons – please listen with understanding, not judgment or resentment. Seek first to understand. 

When we react with anger, it’s like we take the behaviour of others and stab ourselves with it. Then we project our hurt onto them and view them as the villain. No one here is the villain. There is no us against them. We are all in this together. Every single one of us.

So please, if you are feeling grumpy, take a moment to care for yourself. If you find you’re feeling angry or impatient when around others, try these super simple tips:

  • Breath: full and deep. Feel your stomach expand on your inhale, and feel the air on your nostrils as you exhale
  • Notice: what do you and the person have in common. (Trust me, there will be something)
  • Take care: what do you need? Honour your boundaries and step back to create some distance. But as you create that distance, know that it’s about a virus, and not about distancing from another human being. 
  • Honour fear: if you are scared, protect yourself. Wear your mask, and use a mantra: I am safe and I am doing what I can to make a difference.

Every single one of us can make a difference in this world. So be kind. What we’re all going through right now is going to pass. But we need social connection forever. Make yours meaning. Find the common ground and anchor into it. You’ve got this. 

Shift out of Shame

Shame creates a lack of worth within us. It seeps into our body and our emotions, creating a psychological barrier through fear and disapproval and rejection – so why on earth are we using it against ourselves?

If you have been shaming yourself as a means to push towards a change you want, I hereby challenge you to try a different approach. Shame creates a shutting down response in the brain – and I want to keep your brain on-line, and help you achieve your desired change with compassion and energy and determination. There will be no shutting down here friends!

Where ever your inner voice of shame originated from, when you hear it rear its ugly head, acknowledge it for what it is (“Oh, hello there Shame”), and anchor into the present moment with a deep breath. What could you say to yourself instead, to start cultivating an attitude of acceptance and compassion? 

Not sure how to cultivate an attitude of acceptance? Check out the following list and do one item from it every single day. Or, if you have a strategy that works for you, share it in the comments so that we can all learn from and encourage each other!

  • Smile at yourself
  • Laugh at your mistakes
  • Acknowledge the efforts you make, no matter how small
  • Practice not taking things personally (Need help with this one? Check out The Four Agreements, by Don Miguel Ruiz
  • Acknowledge that you aren’t, won’t, and don’t ever need to be perfect. Go on, exhale perfectionism and inhale “I am enough
  • Practice interrupting negative self-talk (try “There I go again…” and then anchor back into the present moment)
  • Move your body if you start to feel stuck in negative thoughts

You can not shame yourself into change – shame will serve only to deflate your energy and dampen your self-esteem. So what is the smallest thing you can do today to be more self-accepting? 

Protective Figure Imagery

The Courage, by Lora Zombie

The image feature in this article is titled The Courage. When you look at it, what qualities do you see? Power, strength, fearlessness, confidence, protectiveness, loyalty? For years I have had artist Lora Zombie’s work in my counselling office. Everyone asks about the art, and for many, the artwork is equally as powerful for them as it is for me. But when The Courage came out (the image featured in this article), I felt the need to share why I find some of Lora’s art so powerful.

When working with trauma in counselling, it is important for individuals to feel emotionally prepared. In EMDR therapy, preparation is done with information sharing and psycho-education, collaboration and transparency, and emotion regulation strategies such as distancing, containment, and resourcing. It is resourcing that I am going to be specifically talking about in this article. 

Resourcing, (also referred to as Resource Development, and Ego Strengthening), is about cultivating strategies that will enable clients to shift out of overwhelming emotions and also to connect with positive resources within themselves. It is the “secret sauce” in trauma work because in order to do the work, clients must be sufficiently stabilized and they must have some ability to regulate emotion

There are many strategies used to assist individuals in developing these abilities. One such strategy is about connecting, through visualization, with a protective figure. A protective figure can be real or imagined, and it is unique to each individual. When we connect with an image of our protective figure being ferociously protective of us, we take the time to notice all the qualities our protective figure possesses. We connect with the sensations in our body that shift as we connect with the image, the emotions, and the positive cognition that goes along with it. As we focus on the protective figure image, emotion begins to settle. What is really happening, is that we activating all those powerful qualities within ourselves. Not only does the image strengthen our ability to settle strong emotion, but it also fosters a sense of empowerment, and cultivates love and compassion

When we lack actual internal resources for processing trauma, the stored negative experience of the trauma can overwhelm our capacity for positive experiences, self-esteem development, and resiliency. Regulating emotion becomes very difficult. Once we have developed the protective figure imagery in counselling, we can later bring up the image in our imagination (in our mind’s eye), perhaps when feeling vulnerable, threatened, or fearful – even during trauma processing. The image becomes an anchor and a source of strength to be drawn upon during healing. (Please note: the resources used during the preparation phase of EMDR are unique to each client).

Lora’s latest artwork The Courage is such a beautiful depiction of the protective figure. I highly recommend it for any counselling space. Check out more of Lora’s work here: https://lorazombie.com

References:

Parnell, L. (2007). A therapist’s guide to EMDR: Tools and techniques for successful treatment. New York, NY: W. W. Norton & Company, Inc.

Parnell, L. (2008). Tapping in: A step-by-step guide to activating your healing resources through bilateral stimulation. Boulder, CO: Sounds True, Inc.

Teal, A. (2018). Super resourcing: An integrative protocol for healing early attachment wounds. (EMDRIA Approved training)

EMDR in your Therapy Session, Part 2

Ever wondered what EMDR looks like in a counselling session? EMDR – which stands for eye movement desensitization and processing, is a therapeutic approach with a wide range of applications. Research has demonstrated that EMDR is effective for working with experiences of trauma (and post-traumatic stress), anxiety, phobias, and addictions, to name just a few. To learn more about the components of EMDR, please read Part 1 by clicking here.

There are eight stages to the process of EMDR therapy. It begins as many therapies do: building rapport and getting a sense of what brings you in and your history. Knowing your story helps your Counsellor understand your needs in counselling, any troubling symptoms that need immediate attention, and also helps you both collaboratively create a treatment plan.

The next stage shifts into preparation, or resourcing. “Resourcing” is the common name for developing emotional coping skills. It involves developing the tools needed for emotion regulation. This phase involves learning to notice and move through strong, overwhelming emotions as they arise. It’s the part of therapy that works with treating the symptoms (the pounding heart sensation of anxiety, excessive worry cycles based on past experiences, sleep disturbance, etc.). In EMDR, we work with a rating scale called the Subjective Units of Distress Scale (SUDS for short). It’s a rating scale from 1 to 10, where 10 is the most distressed you’ve ever felt and 1 is no distress at all. The scale is a helpful way for therapists to attune to their clients, and also for clients to notice their own progress in a session.

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Developing and strengthening emotional coping skills is important because moving into processing trauma too soon could cause a person to feel unsafe and emotionally flooded. With your Counsellor’s help, the intention is to learn to be present with emotion without being overpowered by it; learning to turn down the volume on some emotions as you need to, and ultimately helping you feel safe with the counselling process.

The experience of trauma can leave us feeling unsafe, that is why cultivating a sense of safety has to be a primary focus.  Also, it’s okay to go slow and develop rapport with your Counsellor: you need to feel comfortable and understood (and dare I say, have a sense of trust) before you disclose all the tough stuff to someone. And, it is super important that you build the emotional coping skills to be okay after and between sessions. EMDR respects these important features of trauma work.

With the ability to regulate emotion and connect with a degree of internal safety developed, we can begin the next stages of EMDR: Desensitization.  (Read more about this stage in Part 1 of this article.) Desensitization is where trauma processing begins. For those of you wondering what on earth this part of therapy looks like, let me demystify it for you. 

During this trauma processing stage of EMDR, a session starts out with resourcing and then moves into target selection (which just means you choose what the session focus will be). Because I work with trauma, that often means we want to start out with the first traumatic memory or the worst traumatic memory. Wait! Please don’t slam your laptop shut and storm off – I know that can sound frightening, but you will be ready for this stage because of all your hard developing and practicing emotion coping skills during the preparation stage! 

Once we’ve got that memory selected, we connect the negative belief that goes with it, the emotion it evokes, and where you feel it in your body (the sensation of the emotion). 

Side Note: Why do we Need to Cultivate Awareness of the Felt Sense of Emotion?

Cultivating awareness of how we feel emotion in our body is super important. Trauma can often leave folks feeling disconnected from their body. They can get caught up in staying in their head (thoughts), because perhaps it feels safer. However, our body still carries all that tension. Maybe it gets experienced in the form of stomach aches or digestive problems, holding the breath/shallow breathing, muscle tension, or a clenched jaw. This disconnection from the felt sense can become so habitual, that many folks stop noticing it. But all that tension and unrecognized dis-ease can cause all kinds of health problems. 

So, with the pairing of the trauma memory, with the negative belief, the emotion it evokes and how distressing it feels, and how you sense it in the body, we add BLS and start processing that old memory. Whatever your distress level was at the beginning of the session, your therapist’s goal is to guide you through the processing to get that number down so that you are anchored in a sense of internal safety when the session ends. 

And here is the amazing part: as the BLS is repeated, the brain is processing the trauma to reconcile it as a past event. When your brain and your body can reconcile trauma as a past event, it means you can anchor into the present moment. You shift out of survival mode and can more accurate attest that you truly are safe now. 

Emotional Activation (Feeling Triggered):

Have you ever noticed that when something in the present moment reminds you of a trauma you experienced, the emotion that arises feels completely raw and overly-excessive to the present situation you are in? That is what unprocessed trauma can feel like. There is an amazing little brain system we all have, called the limbic system. Its sole job is to keep us alive. Experiencing trauma can keep us popping into that limbic system survival mode way too frequently. Constant survival mode living can leave people feeling emotionally reactive (as though we are constantly in fight, flight, or freeze), and emotionally exhausted. The brain just doesn’t recognize that the trauma is over, and that you are safe now. That is why counselling is so important for your overall health and functioning.

During processing with BLS, emotion becomes less intense. One of the session goals is to keep reducing activation – getting your SUDS number going down so that you are shifting more and more out of distress. 

EMDR_Congition_ListAs a result of all that emotional processing, you are able to connect with a positive belief, and we install it with BLS (the next stage in our 8 stage model). Instead of the negative belief a person started the session with, such as perhaps “I am not enough”, folks now get to decide what positive belief is more preferable, (such as “I am worthwhile”, or “I did the best I could”). We link the positive belief in with BLS so that when the client thinks about the past experience, he or she is no longer washed over with thoughts of being not enough – and in fact, that old negative belief feels distant. The past event really does feel over and anchored in the past, and linked with the positive belief. It may still evoke a degree of emotion (after all, we can not erase the past from having happened), but the sadness or fear that arises going forward when the memory is recalled, will be less intense and will fit the situation you are in.

Containment metaphors might be used at the end of a session, as well as a body scan. The body scan is a super useful tool to strengthen the positive sensations associated with the positive belief, and also for identifying any distress still present. The final stage of the session (but not yet the 8th stage of EMDR), is a debriefing of sorts, where we can review strategies for anchoring in the present moment, handling emotion as it comes up, and discussing what to expect after the session in terms of emotions percolating and taking care of self between sessions. 

The subsequent session starts out with an exploration of anything that came up between sessions, and a re-evaluation of thoughts, beliefs, emotions, and sensations connected with the work from the previous session That’s the eight stage of EMDR, and then the process continues until folks feel as though they have worked through the pieces they entered into counselling to address. 

I hope this summary of what EMDR in a therapy session looks like has been helpful. Remember,  while we can not erase traumatic experiences from your memory, with EMDR the brain can reconcile them as a past events. We can lessen the intensity of the emotion the memory evokes, as well as the meaning attached to it. We learn to notice when we are shifting into the limbic system and either act to maintain safety or anchor back into the present moment acknowledging the memory as well as our present moment safety.  

If you want to learn more about EMDR, please check out the EMDR International Association website or EMDR Canada. Both of those websites also list EMDR therapists by location, so you can even tap into those resources to find a practitioner close to you. 

Be well.

EMDR in your Therapy Session

EMDR Therapy

Part 1

There are many therapeutic approaches Counsellors can use when working with clients on their goals in therapy. This article is intended to describe EMDR therapy (Eye Movement Desensitization and Reprocessing). Originally developed by Francine Shapiro for use with post-traumatic stress, EMDR therapy is also an effective approach for working with fears and phobias, addiction, and anxiety. It also works to strengthen feelings of calm and confidence. 

Disclaimer: please know that no therapy is one size fits all. There are many layers and approaches in counselling psychology and also to the complex issues people experience. This information is intended to introduce you to attachment-focused EMDR, a variation of EMDR developed by Laurel Parnell (The Parnell Institute). My aim is to be informative and brief, leaving you with an understanding of what EMDR is prior to starting therapy.

The Body Holds Emotion

EMDR is a somatic approach to therapy, which means that in addition to exploring thought processes and emotion, we also explore how the body is holding emotion (that’s “the felt sense of emotion”). When a traumatic event happens, we humans tend to become flooded with emotion and our brain doesn’t process and store the memory properly. What happens is that parts of the event (thoughts, emotions, body sensations, images, and smells) stay unprocessed in the brain. What this means for people is that reminders in day-to-day life can activate those unprocessed memories, causing it to feel as though the trauma is happening all over again. You know in your rational brain that it isn’t – but the felt sense of emotion that spikes up so fast that makes it feel as though danger is very real and present. Using EMDR, we work with the memories that are causing the present-day distress and we “reprocess” them. This means we are working with all the elements of the present, past, and even future.

It’s All in the Name

The name of the therapeutic approach is a long one, so let’s deconstruct what each component the name “EMDR” refers to.

EMDR incorporates eye movements, which is a type of bilateral stimulation (BLS). This is a core feature of EMDR. The term ‘bilateral’ refers to two sides: eyes moving back and forth in a rhythmic side-to-side pattern. Thanks to research and new technologies, the bilateral stimulation used during EMDR can be visual (the eye movements), auditory (sound), or tactile stimulation (touch). Bilateral stimulation ensures both hemispheres of the brain have an active role in memory processing.

Visual bilateral stimulation can be created by the therapist moving their hand back and forth, or with a light bar. A light bar looks exactly as it sounds: it is a sleek bar of lights, and a light flashes on one end of the bar and then the other, and back and forth it goes. The client follows the lights with their eyes, side to side in a rhythmic pattern, thus the term “bilateral”.  Auditory BLS is facilitated with earbuds, with a sound being played alternating from one side to the other.  Mark Grant has developed a powerful app that utilizes EMDR with auditory BLS, called Anxiety Release. Tactile BLS can be facilitated with tapping rhythmically from side-to-side.  I use a little hand held device with 2 parts that a client holds, one in each hand, and it facilitates bilateral stimulation (BLS) with a brief pulse, or vibration back and forth. It feels the way your smart phone does with the silent mode vibration.

More about Bilateral Stimulation (BLS)

Bilateral stimulation is a core feature of EMDR because through repeatedly activating the opposite sides of the brain, it harnesses the power of the accelerated information processing model and aids in releasing emotional experiences that feel ‘stuck’. It can be said that this process mimics REM sleep. You may have heard of this before: when we are sleeping and in the REM stage of sleep, our brains have a chance to process the events of the day. In trauma, we know that memories get stuck – they don’t get processed and worked through. So by using BLS as part of the trauma processing, we help our brains to finish processing those distressing events. As the troubling images and emotions associated with the disturbing/scary/upsetting event are processed while paired with repeated alternating activation (BLS) the memory consolidates, the distressing bits feel resolved, and a more peaceful emotional state is achieved.

There is a lot of emotion packed into the trauma memories.  As you read this, you might be feeling worried that if you start working with a past trauma, the level of emotion it evokes might be too much to handle. In EMDR therapy, therapists are trained to help folks through the process. So while working through distressing memories does evoke emotion – we go slowly, we keep our focus narrow, and build emotion regulation skills first. This way emotion can feel more manageable, and the body can start to regulate.

A Few More Neat Facts About Bilateral Stimulation:

  1. BLS can help the body relax (all those muscles that were tense without you even being aware they were tense suddenly relax a bit)
  2. It can help unstick our thinking so that we feel a greater sense of cognitive flexibility (thoughts flow and feel less stuck and rigid on the troubling topics)
  3. It can help improve our concentration
  4. And, my favourite effect of BLS: it helps us ease into the awareness of the distance between the present moment and the upsetting event. This means that the issue or event worked on during the counselling session feels smaller and further away; more anchored in the past and not so volatile and active in the present

Desensitization means that we’re working with the intensity of emotion felt when recalling a disturbing/scary/upsetting event.  Desensitization refers to the process of becoming less and less distressed with the memory of an event that was disturbing/scary/upsetting but that is now over.  We can not undo the past or erase the memory of it, but we can learn to turn down the intensity of emotion felt when recalling it.

Reprocessing means that some memories of the disturbing/scary/upsetting event weren’t processed at the time the event occurred. There are many brain systems that are involved during trauma, and many more that are shut down, or suppressed, during the event. This means that the traumatic moment isn’t stored in the brain the way a non-traumatic event gets stored. In EMDR, reprocessing means that we work on understanding and new integration so the memory of the disturbing/scary/upsetting event becomes useful instead of so disturbing. By reprocessing it, in a very titrated and strategic way, the memory comes to be stored as part of an integrated memory system: it starts to feel like the event is in the past.

Here are a couple of things to keep in mind, regardless of the therapy you choose to access in your counselling session.

  • Going slowly is important. Building up emotional coping skills prior to working through trauma is a helpful way to ensure sessions feel more manageable
  • Therapy is rarely one size fits all. Your therapist will work on getting to know you, your story, and your needs, in order to best help you work through your goals in counselling.

In the next article, I will go over what a typical EMDR therapy session may look like. Stay tuned for it!

–> Click here for Part 2: What EMDR Looks Like in a Therapy Session