# Presentation: 643483

## 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 Symptoms

| Symptoms 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

**Notes:**
Similar to what happens in therapy

## 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 breathing
Chest pain, dizziness, tingling around mouth, in fingers
Severe pain in abdomen, headache
Get stuck in flashback |
| Optimal Zone for recovery | Optimal Level of emotion
Sadness, 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 faster
Breathing 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 emotion
Sadness, 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 faster
Breathing 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 irritation
sense 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.
**O**bserve
**I**magine
**A**ct
**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.
**O**bserve
**I**magine
**A**ct
**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