TSR Training for Veterans

David A Fohrman, M.D.

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

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)

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)

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

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

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

Biological reason for PTSD SymptomsSymptoms of PTSD Biological reason

Keep thinking about event even when do not want to, flashbacks, nightmares

Memory system automatically reactivates event so it can re-process these abnormal, trauma memories

Can't remember important events, 'space out' under stress or dissociate

When experience high levels of emotions, voluntary part of memory system temporally turns off

Chronically feel anxious, nervous, or 'on edge' or unsafe: like we are in a potentially dangerous situation.

Trauma memories are not only sights and sounds, but are also the extremely strong negative emotions (such as fear and helplessness) you felt during the event.

Difficulty concentrating, difficulty falling and staying asleep, frequently feeling irritable, and easily startled.

Trauma memories activate our flight or fight response – chronically doing this make us have difficulty falling and staying asleep, frequently feel irritable and causes us to startle easily

Body’s Memory System

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

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.

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

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

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

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

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

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

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

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

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

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!

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

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

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 memories which will make it harder to fix them in the future

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

Optimal Zone for Recovery

Level of activation

Level of Emotion Thoughts Body symptoms

Too high/ Not able to concentrate

Excessive: extreme fear, panic, helplessness, rage, despair, shock, horror, extreme feelings of guilt, shame or self loathing

“ I am going to die!”“Help! I am trapped”“I can’t think!” “It’s never going to end!”“Things are out of control!”

Feel very nervous/anxious panic stricken. Chocking sensation/difficulty

breathingChest pain, dizziness, tingling around

mouth, in fingersSevere pain in abdomen, headache

Get stuck in flashback

Optimal Zone for recovery Optimal Level of emotionSadness, tearfulness, irritation, frustration, thoughtfulness, concern, agitation and low levels of anxiety and nervousness

“I don’t like how I am feeling but I Know I can feel this way and still be ok” “I am feeling irritated/sad/concerned/ etc right now” “Feeling this emotion (put in emotion) is hard but I think this is helping”

Feel awake, focused and aware of your surroundings

Heart beating a little fasterBreathing faster

More aware of sights, sounds, smells, May have some feelings connected to

flashback experience

Too low/ not interested enough to concentrate

Little or no emotional reaction to the topic or mild

irritation

“I’m bored”“This is waist of time”“I would rather …. (be doing (something else)

no symptoms

Handout Your optimal Zone for Recovery

Level of activation Level of Emotion Thoughts Body symptoms

Too high/ Not able to concentrate Excessive: extreme fear panic helplessness rage despair shock, extreme feelings of guilt, shame or self loathing other:_____________ other:_____________

“ Get me out of here!” “Help! I am trapped” “I can’t think!” “It’s never going to end!” “Things are out of control!” other:_______________ other:_______________

Chocking sensation Difficulty breathing Chest pain Severe nausea dizziness, tingling around mouth, in fingers pain in abdomen, severe headache other:_______________ other:_______________

Optimal Zone for Recovery Optimal Level of emotionSadness, tearfulness, irritation, frustration, thoughtfulness, concern, agitation and low levels of anxiety and nervousness other:_____________ other:_____________

“I don’t like how I am feeling I Know I am going to be ok”

“I am feeling irritated”I am feeling sad

I am feeling concerned other:_____________ other:_____________

Feel awake, focused and aware of your surroundings

Heart beating a little fasterBreathing faster

More aware of sights, sounds, smells, May have some feelings connected to

flashback experience other:_____________ other:_____________

Too low/ not interested enough to concentrate or wish to actively

avoid thinking about

Little or no emotional reaction to the topic

mild irritationsense of vague anxiety other:_____________ other:_____________

“I’m bored” “This is waist of time” “I would rather …. (be doing (something else) other:_____________ other:_____________

no symptoms mild nausea sense of unease other:_____________ other:_____________

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

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

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

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

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

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!

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

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

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

Heal -reconnect to your beliefs

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

Handout - Identify if you have trauma induced beliefs

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”

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

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

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

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