Trauma: an overview of this vivid landscape

Content warning: please consider how to care for your wellbeing before reading, or reading when a sense of equilibrium has been or can be regained, self-care measures can be undertaken and planned for, there is emotional energy available to enact and maintain strategies to keep safe and plan some nurturing activities.

Remember that trauma can be addressed and overcome: we can all survive, thrive and grow.

Content information: I have adapted this content from the professional development ‘Sharing Our Knowledge Mental Health and Domestic Violence Cross Sector Collaboration Program’, 2016, that I wrote as the Project Officer for services to increase clinical efficacy through collaborative, inclusive, trauma and gender-informed practice for people accessing services.

I want to write a little bit about Trauma because it is the horror few people realise that we are all vulnerable to (it doesn’t discriminate). How much we are affected by it — and for how long — depends upon a complex range of external and internal circumstances, (all of which can be addressed), that are unique for everyone and I will explain what we can do about it, but first: what is it?

‘Traumatisation occurs when both internal and external resources are inadequate to cope with the external threat’ (van der Kolk, B., 1989). Bloom, S. M.D. Trauma Theory Abbreviated from the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999. In other words, resilience skills, supportive relationships, coping strategies and belief systems can be protective to an extent, but there are life experiences that are extreme and threaten wellbeing and safety. These extreme experiences cannot be completely prepared for because reactions are initially automatic rather than consciously chosen and it is impossible to predict how a person will react following the event. The effects of traumatic experiences are unique to the individual, but share some common themes. The three ‘self-capacities’ that are intrinsic to respond effectively to challenging life experiences (and the initial development of these) is entirely correlated with having a healthy relationship with parent(s) or caregivers (Maté 2008): sense of self/ identity; boundary awareness and affect regulation. (Briere, 1996). It is also these three core capacities that are affected by traumatic and stressful experiences.

For children/ youth: 
• Type 1 traumas: ‘acute traumas’ are caused by a single traumatic event and 
• Type 2 traumas: ‘complex traumas’ are caused by multiple, prolonged, repeated, traumatic events
(Developing a Trauma-Informed Therapeutic Service in the Australian Capital Territory for Children and Young People Affected by Abuse and Neglect September 2014 ACT Government Community Services Kate Gimson (Psychologist) Senior Project Officer and Alison Trewhella (Social Worker) Project Officer).

‘Complex trauma’ ‘is cumulative, repetitive and interpersonally generated, and includes ongoing abuse which occurs in the context of the family and intimate relationships. Complex trauma usually involves a fundamental betrayal of trust in primary-care relationships, because it is often perpetrated by someone in close contact with the victim. Unlike a one-off event, the cumulative impact of premeditated and multiple episodes of abuse involves compounded impacts and persistent effects. Complex trauma places the person at risk of mental illness and complex post-traumatic stress disorder and may impact physical health and psychobiological development’. (Bateman, J., & Henderson, C., (MHCC) Kezelman, C., (Adults Surviving Child Abuse, ASCA) 2013, Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group, Mental Health Coordinating Council (MHCC)).

‘Vicarious Trauma (VT)’ ‘… is described as a transformation in a worker as a result of working with a person who has been traumatised. Vicarious trauma is a cumulative effect of working with trauma, which can affect many aspects of a person’s life. It may consist of short-term reactions, or longer-term effects that continue after the work has finished. Some effects of vicarious traumatisation parallel those experienced by the survivor, and can lead to a person experiencing the symptoms of post-traumatic stress disorder (PTSD)’. Bateman, J., & Henderson, C., (MHCC) Kezelman, C., (Adults Surviving Child Abuse, ASCA) 2013, Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group, Mental Health Coordinating Council (MHCC)

A few infographics I like to use to begin explaining trauma are:
Understanding Trauma: When bad things happen to good people SAMHSA http://www.dhcs.ca.gov/individuals/Documents/UnderstandingTrauma-WhenBadThingsHappen-SAMHSA-overview-infographic.pdf 
How to manage trauma SAMHSA http://www.integration.samhsa.gov/clinical-practice/Trauma-infographic.pdf 
Chronic Maladaptive Pathways Table Community Works 2010 http://www.sanctuaryweb.com/Portals/0/2010%20PDFs%20NEW/2010%20Bloom%20TABLE%20Chronic%20Maladaptive%20Pathways.pdf 
Complex Responses to Toxic Events Table 2010, Community Works http://www.sanctuaryweb.com/Portals/0/2010%20PDFs%20NEW/2010%20Bloom%20TABLE%20Complex%20Responses%20to%20Toxic%20Events.pdf

The three core capacities that are essential to be able to effectively respond to challenging events are a sense of self, boundary awareness and affect (feelings, sensations, etc) awareness and regulation. These are affected by traumatic events and may not fully develop if there is unresolved trauma in childhood. They will need to be regained/ gained, developed/ redeveloped following a traumatic event.

Sense of self includes beliefs, values, the sense of right and wrong, hope, meaning, likes and dislikes, sense of justice and mercy.

When the core-self is under-developed in childhood (or affected by trauma), the capacity for self-reflection is diminished, leading to withdrawal and dissociation from feelings and the inner and outer world. This prevents the development of the capacity to identify, interpret, communicate or manage and self-regulate affective (feeling) states, or develop coping strategies. It also prevents the development of boundary awareness. The avoidance/ withdrawal/ dissociation from the self is a vulnerability which causes hypervigilant assessing of the environment for threat and conversely dulls the awareness of personal boundary breaches.

Avoidance and intrusive symptoms of nightmares or flashbacks (re-experienced, non-verbal, traumatic memory) are interacting and escalating symptoms of Post Traumatic Stress Disorder. As these symptoms escalate, the person may withdraw more and become more isolated from all meaningful aspects of life. This alone can contribute to the development of maladaptive coping strategies such as self harm or addiction as people seek new ways to cope. (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999).

These coping strategies suggest that the person who has experienced traumatic stress is attempting to regain control of their own body and effect a reaction: possibly utilising self harm and suicidal ideation to counteract numbness, starvation to numb to counteract excessively strong emotions. Addictive behaviours can either numb or increase a sense of feeling. (Fisher, 2003). People who have experienced chronic traumatic stress and maladaptive coping strategies are more likely to die from all causes. (Vacaro and Lavick, 2008). (Poole, N., Greaves, L., Ed. (2012) Becoming Trauma Informed. Toronto, Canada: Centre for Addiction and Mental Health)

The inability to cope with stressors causes hyper-reactivity, development of maladaptive coping strategies (causes harm to self/ others); may lead to isolation to avoid triggers. The inability to cope may cause a person to disconnect from themselves and others: numbing, avoiding triggers and restricting their environment. As a result, they may develop a pervasive, numb affect, with the consequence of isolation, a sense of helpless, hopeless, depression, emptiness, alienation and of being dead inside. To counteract these consequences, a person may attempt to feel more alive and connected to themselves through high risk activities and other intense stimuli. (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999.)

If emotional numbing continues as a coping strategy, the trauma remains unprocessed preventing the development of increasingly skillful coping strategies and the avoidance of triggers increases with general hyperarousal.

Boundary awareness develops from self-awareness and the awareness of a person’s own and other’s idealogical, rights, physical, social, emotional and all other boundaries. This includes: 
• the right to say ‘no’ 
• take care of own needs and not prioritising others needs to the detriment of the self
• identify likes and dislikes
• identify feelings, beliefs and perspectives
• facilitate respectful, healthy relationships
• power balance and imbalance
• ability to empathise and be emotionally intimate
• remain and concentrate on the present
• effectively maintain value-based choices regardless of peer pressure
• learn from mistakes (Friedman and Boumil, 1995)

Multiple, prolonged, repeated traumatic events cause ‘toxic stress’ from cortisol and adrenalin constantly flooding the body. This changes the development of the brain in childhood, the ability to concentrate, cope with stress, regulate emotions, self-comfort or develop cognitive processing and problem solving skills and affects health and wellbeing.

Affect awareness and regulation include the ability to discern and manage emotional states and is initially learnt in childhood from parents or caregivers’ responses. This skill is developed through safe, nurturing, responsive relationships and environments. It can, however, be developed after childhood.

Feelings following a traumatic event are usually extreme and feel unmanageable.

Affect regulation includes the development of coping strategies, stress management strategies and learning to self-soothe.

Maladaptive coping strategies (harmful to self/ others) develop to effect short term relief and are caused by the inability to problem solve as a result of the effects of trauma. They are a survival mechanism, without the benefit of the ability to assess or consider consequences. The goal is to reduce or avoid pain and stress, even disconnecting from feelings and body. The ongoing use of maladaptive coping strategies can lead to a reduction of coping skills and the prevention of the development of frustration tolerance (the ability to manage frustration). This is because maladaptive coping strategies usually afford immediate relief, even if they have adverse consequences, so healthier/ safer strategies aren’t utilised. This leads to increasingly reactive responses to stressors, resulting from the decreasing ability to cope. Poole, N., Greaves, L., Ed. (2012) Becoming Trauma Informed. Toronto, Canada: Centre for Addiction and Mental Health.

Disconnecting from or diminishing emotions and emotional numbing can have implications for the ability identify emotions and the ability to empathise.

‘The core experiences of psychological trauma are disempowerment and disconnection from others’ Herman, J., 1992: 2001, Trauma and Recovery: The Aftermath of Violence — from Domestic Abuse to Political Terror. Pandora, UK

Another effect of trauma and chronic stress on the body is that endorphins are released. Endorphins reduce anxiety, pain and aggression and improve mood and sense of wellbeing. Chronic exposure to trauma causes almost a constant exposure to endorphins and changes the functioning of the biological system.

This can cause people to become conditioned to high levels of endorphins, only feeling calm when experiencing environments that induce anxiety, fear, irritability. In calm environments, they will again feel hyper-aroused. This process explains why children and adults who have experienced trauma will sometimes enact violence, cause disruption, engage in criminal activity, alcohol or other drug misuse, self harm, because they are engaging in these activities as an attempt to regulate their biochemical system to feel calm and improve their mood. Therapeutic attempts to address a person’s trauma must also address this aspect of the person’s reaction to it. (van der Kolk and Greenberg, 1987) (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999.)

Trauma affects all areas of life and people’s worldview, including their perception of safety, the self, trust, power and control, esteem and intimacy (in relation to themselves and others).

Trauma affects all domains of functioning: affect (feelings and sensations), behaviour and cognitive. Trauma causes adaptive changes across the three domains, including pervasive feelings of stress and helplessness. It interferes with the social, emotional, cognitive and neurological tasks of the developmental stage at the time of the event, which prevents the brain from integrating ‘sensory, emotional and cognitive information into a cohesive whole’, and impairs affect awareness and management, behaviour management and consideration of consequences, memory, cognitive functioning and processing.

Affective Domain of Functioning: Intense emotions that feel impossible to control are commonly experienced as are constant feelings of danger and vulnerability.

Traumatic events and strong averse emotions cause the prefrontal part of the brain to shut down and trigger the ‘freeze, flight or fight’ response for survival. When strong averse emotion, including fear is experienced, the ability to think, speak, process, consider consequences of actions and remember the experience in the verbal memory system is impaired and the non-verbal memory stores the experience instead, ‘frozen in time’. These memories are not remembered, they are relived (van der Kolk, 1996). (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999).

Also, people may engage in high risk activities to counteract the effects of numbing.

The body automatically responds to stressors to survive: fight, flight and freeze (tonic immobility).

Behavioural Domain of Functioning: the constant threat of danger exhausts the body and can confound the person’s ability to discriminate between real and potential threats: everything and everyone feels unsafe. The amygdala in the limbic system controls the Autonomic Nervous System (ANS), which triggers the adrenal gland to release chemicals into the blood that prepare it to act. This disables the functioning of non-essential systems, organs and the brain’s frontal cortex.

The fight or flight response to threat, controlled by the ANS, comprising the sympathetic nervous system which controls the ‘fight’ reaction of nerves, organs and muscles in the response to danger and the parasympathetic nervous system, which controls the body’s ‘freeze’ (tonic immobility) response to danger and relaxation, return to base-line/ normal functioning when threats pass and the person is safe. (Poole, N., Greaves, L., Ed. (2012) Becoming Trauma Informed. Toronto, Canada: Centre for Addiction and Mental Health) (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999)

An effect of stress is that the body and brain release hormones to facilitate impulsive action to ensure safety. This process is automatic and impairs the capacity for cognitive processing, meaning that the consequences of those actions are not considered, nor risks mitigated. It is possible the person may become physical and violent.

This explains the inclination to fight for control and power as a means to reduce anxiety and increase a sense of safety when the victim becomes the abuser. This can be influenced by gender norms. (Real, 1997). This has implications for further traumatisation, undermining the sense of self and the self in context of others and the world and support needs to be provided for the person to verbalise, process and attribute meaning to their experiences with unconditional positive regard, accurate empathy, congruence and without collusion or judgement while working towards change. (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999.)

Automatic defensive reactions can also develop when the experience of threat is constant. As these are automatic responses, when threat is constant, the amygdala in the limbic system that controls the ANS, learns to automatically react defensively to both threatening and non-threatening situations. This leads to dysregulation in the brain and body which leads to an underlying, reactive chronic fear-based reaction of either numbness or dissociation, or hyperarousal and hypervigilance when danger is interpreted in the environment, which keeps the psychological, emotional and physical effects of the trauma alive (Poole, N., Greaves, L., Ed. (2012) Becoming Trauma Informed. Toronto, Canada: Centre for Addiction and Mental Health) (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999).

Avoidant behaviours are not beneficial because they reduce the development and utilisation of coping strategies; the exception being to unsafe people, substances and places: these probably should be avoided.

Hypervigilance is used because the world and the people in it are perceived as unsafe.

People may unconsciously act out traumas (traumatic re-enactment) (James, R. K.,1994).

Cognitive Domain of Functioning: Stress, averse emotion and trauma shut down the prefrontal part of the brain, impairing memory, the ability to remember, the ability to think, speak, communicate, focus, plan, consider risks and consequences, process information and experiences.

Constant exposure to traumatic stress exhausts the body and impairs the ability to discriminate between real and perceived threat.

Traumatic memories are stored as dissociated sensory and perceptual fragments, without a narrative or a connection to time frames meaning that the traumas are re-experienced in the present rather than remembered, re-lived through emotions, flashbacks, non verbal behaviour or may be re-enacted unconsciously. These can sometimes be triggered through internal or external stimuli. (Van der Kolk 1994). Poole, N., Greaves, L., Ed. (2012) Becoming Trauma Informed. Toronto, Canada: Centre for Addiction and Mental Health Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999.

During a flashback, the body and brain respond as if the traumatic event is happening in the present. (Van der Kolk 1994, 1996).

Memories that cannot be recalled, cannot be processed, explored, learnt from, evaluated, preventing growth and change. This also means that the person is more vulnerable to remaining stuck with the memory and/ or in the situation because it is not processed and healed.

Trauma causes inflexible ‘black and white’ thinking, the intolerance of mistakes and prevents the development and utilisation of effective belief systems to respond to adverse and everyday events. Belief systems evolve through processing experiences and trauma impairs the ability to cognitively process and also contributes to pessimistic interpretations of life generally. (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999).

This further reduces the ability to cope. (Bloom, S. M.D. Trauma Theory Abbreviated From the Final Action Plan: A Coordinated Community-Based Response to Family Violence, Attorney General of Pennsylvania’s Family Violence Task Force, October, 1999).

The effects of cumulative traumatic events affect the ability to trust, destroy the sense of safety and comfort from relationships: everyone and everything is unsafe.

The following videos may assist understanding: 
Bessel van der Kolk: Changing the Paradigm 2015 Developmental Trauma Panel https://www.youtube.com/watch?v=-pCbbOWKB2I 
Bessel van der Kolk The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma https://www.youtube.com/watch?v=53RX2ESIqsM

Addressing Trauma

Traumatic memories cannot be processed until the person is safe, until they are functioning better across the affective, behavioural and cognitive domains have developed or re-developed a sense of self, boundary awareness, coping strategies, affect awareness and regulation. Support is invaluable and increased coping strategies are essential.

Increasing Resilience: having a framework to refer to is sometimes helpful when creating a plan for increasing wellbeing. Positive Psychology provides helpful structures, as does Albert Ellis’ books based on his Rational Emotive Behaviour Therapy. Increasing daily relaxation techniques, stress management and meaningful activities are an essential foundation for the work towards processing traumatic experiences.

PERMA (Positive Emotion, Engagement, Relationships, Meaning and Accomplishment) is Positive Psychology’s research-based contribution to our understanding of wellbeing.

Positive Emotion
• Intentionally increasing positive emotions to broaden habitual patterns of thinking and behaving (Frederickson, B. L., 2001) Engaging with self and all others, in all domains of life to fuel the experience of joy, gratitude, serenity, interest, hope, pride, amusement, inspiration awe, love. This requires the ability to identify and manage emotions, identify and protect personal, professional and ethical boundaries, a sense of values and beliefs. Taking time to reconnect with the self, identify likes, dislikes, clarify values and beliefs may be needed when experiencing stressors.

Engagement or ‘flow’
• Utilising strengths in meaningful activities 
• These are activities that completely absorb all attention and lose sense of time passing (Seligman 2012)

Relationships
• Increasing supportive relationships increase in all areas of life
• These reciprocal, supportive, positive relationships increase health and wellbeing

Meaning
• Increasing engagement in ‘higher purpose’ activities 
• Engaging in creative, philosophical, religious, spiritual and/ or ‘higher purpose’ activities increases optimism, wellbeing and personal growth

Accomplishment
• Increasing accomplishment facilitates further skill development and mastery
• A sense of accomplishment facilitates further skill development and a sense of mastery, increasing optimism, increases motivation to achieve more and wellbeing

Plus: Optimism, Physical Activity, Nutrition and Sleep

Professor Seligman on PERMA https://www.youtube.com/watch?v=jqqHUxzpfBI

From birth, people are naturally inclined towards persisting despite challenges, obstacles, frustrations and sub-failures undeterred, focused on mastering goals such as communicating: this is masterful action. As people get older, masterful action needs to evolve to include how to contextualise experiences on the path toward mastery: they need to be taught how to think about failures, feelings, beliefs and how to proceed, leading to optimism and high self-esteem.

Optimistic perspectives lead to the perspective of failures as temporary challenges which can be responded to with action and hope on the path to success and mastery. Effective, accurate disputation and decatastrophization reduce the intensity of emotional and behavioural consequences, increase perspective and the ability to realistically, optimistically create plans of action to address adversity: to persevere despite failures.

So, to achieve mastery, people need to try, fail, persist in facing each of the steps in each complicated but surmountable task. Failures create unpleasant feelings which are daunting, but realistically and accurately feeling them, provide energy and motivation to concretize action to overcome them, recover from the frustration (build frustration tolerance) and sub failures to persistently try until they ultimately succeed and feel good with higher self-esteem.

The ecological framework for resilience considers the dynamic process between risk and protective factors across the following three domains: individual, family and environmental. These domains interact and influence each other and all need to be taken into consideration to increase resilience. (Garmezy, N., 1991; Borman & Rachuba, 2001; Werner & Smith, 1992) Santos, R., Why Resilience? A Review of Literature of Resilience and Implications for Further Educational Research Claremont Graduate University & San Diego State University

A narrative needs to develop for the process of healing to occur, with this further facilitating a ‘time sequence’ (Bloom, S. 1996) This is because the narrative facilitates the creation of a time line and boundaries for the past, present and future.

Traumatic events need to be processed so the verbal and non-verbal memory systems can integrate and people need to be supported to express their experience non-verbally. Non-verbal expression of the traumatic event facilitates the processing of it and reduces the risk of re-traumatisation. (Bloom, S. 1996)

Examples of non-verbal means of expression include: art, music, physical movement and theatre. Using these methods to create an external representation of the experience, then verbalising and narrating feelings, thoughts, the experience, the effects of the trauma and eventually finding meaning can follow (the end stage of processing experiences is developing beliefs.

Sense of Self: Being safe enough to explore and identify the qualities of the Self and the core self: personality, values, humour, love, ethics, beliefs, morals, sense of right and wrong, hopes, dreams, strengths, character, skills, likes, dislikes, relationship boundaries, experiences, feelings, thoughts, knowledge and presence in the world. Sometimes it helps to write a ‘biography’ across these domains, with dot points or a checklist and maybe pictures/ photos, so it is easier to process when re-reading them or adding to them during stressful times.

To connect with specific strengths, the list from Positive Psychology’s VIA Strengths Classification can help people to identify specific examples from their own life, then write them down. This helps to regain a sense of self as well as identify strengths and even areas to strengthen. Identifying these when a person has experienced a crisis or trauma is challenging, so writing them down with someone trusted is helpful and can be used as a reminder during challenging times.
http://www.viacharacter.org/www/Portals/0/Poster.pdf 
http://www.viacharacter.org/www/Portals/0/Character%20Strengths%20Infographic.jpg 
http://www.viacharacter.org/www/Portals/0/Character%20Strength%20Word%20Infographic.jpg

People can identify their own ‘Spheres of Intelligence’, which are the multiple areas of strengths of learning, from Howard Gardner’s Multiple Intelligence Theory. They explain that development occurs uniquely in each individual in context of culture; across multiple domains and to varying degrees. This is very important to identify because trauma impacts on cognitive processing, intelligence tests and memory, so identifying learning preferences and strengths can help to utilise those when needed. The ‘Spheres of Intelligence’ of learning are: 
Verbal/ linguistic: examples include language/ communication skills; sensitivity to the phonetics, rhythm and meaning of words
Logical-mathematical: examples include abstract thinking, conceptualisation, pattern-identifying skills
Visual/ spatial: examples include skills of abstract, accurate, pictorial and image visualisation
Body/kinaesthetic: examples include skills of using the body to do things
Musical: examples include skills of rhythm, pitch, timbre
Interpersonal: examples include: skills of understanding and responding to others
Intrapersonal: examples include skills of understanding self (beliefs values, feelings, thoughts)
Naturalist: examples include skills of identification and categorisation of plants animals and other objects in nature
Existential: examples include skills of philosophy and identifying meaning (Thirteen Ed 2004)

Traumatic Stress and Mental Health challenges can affect the sense of self. Writing lists, having plans and pictures or photos etc of the following topics (amongst others) may help:
• What I am like at my best:
1. What can I do to stay at my best?
2. What reduces my ability to be at my best?
3. What can be done about it? 
• What are all of my strengths/ achievements (these do not have to be related to work etc, these can be anything:
1. What helps me to remember/ acknowledge/ use them? 
2. What reduces my ability to use my strengths?
3. What can be done about it? 
• What supports my wellness daily, weekly, monthly, etc:
1. What is my plan to maintain wellness?
2. What are the barriers to maintaining wellness?
3. What reduces my wellness?
4. What can be done about it? 
• What increases my sense of feeling safe, empowered and included in society:
1. What can I do to increase my sense of safety, empowerment, inclusion?
2. What reduces my sense of safety, empowerment and inclusion?
3. What can be done about it? 
• What increases my sense of meaning:
1. What is my plan to increase meaning in my life? 
2. What reduces my sense of meaning?
3. What can be done about it? 
• What increases my sense of hope
1. What reduces my sense of hope? 
2. What can be done about it? 
• What are my triggers (triggers are the scientific and psychological term for the mechanism where an external or internal stimuli causes an original traumatic memory to be relived (flashback):
1. What increases my vulnerability to triggers?
2. What can be done to manage/ address triggers (without necessarily avoiding them)?
• What are my early warning signs:
1. What can be done to manage this stage?
2. Who can help and who needs a copy? 
• What is my crisis plan:
1. What can be done to manage this stage?
2. Who can help?
• Who are my support people and their numbers:
1. What can be done to manage this stage, eg: do I need to discuss this with them and work out a plan?
2. Who can help?

Resources that may be helpful: 
• WRAP (Wellness Recovery Action Plan) IS 2015 07 08 Final (Mary Ellen Copeland PHD)
https://www.youtube.com/watch?v=3qtBiPvSdkY 
Continuum of Wellbeing (Becker, C., PhD CWP, McPeck, W., Creating Positive Health: It’s More Than Risk Reduction) http://c.ymcdn.com/sites/www.nationalwellness.org/resource/resmgr/WhitePapers/NWIWhitePaper_BeckerMcPeck20.pdf 
• Video: Bernie Siegel: Love, Medicine and Miracles https://www.youtube.com/watch?v=4TwAHC4q2K4 
• Video: The Science of Resilience: Implications for Prevention and Treatment of Depression in Students https://www.youtube.com/watch?v=2dVZMGMMr90 
• Ford, J. D., PHD (2015) An Affective Cognitive Neuroscience-Based Approach to PTSD Psychotherapy: The TARGET Model http://www.advancedtrauma.com/Ford2015JCP_TARGEToverview_1_.pdf 
 
Boundary awareness:
Boundary awareness is easier when people are able to ‘tune in’ to their bodies, which requires relaxation and stress management strategies to facilitate sufficient calm to be self-aware of body cues for discomfort and tuned in and aware of their own and other’s idealogical rights, physical, social, emotional and all other boundaries.

Some more strategies to address boundaries are:
• Identify early warning signs that boundaries are blurring, including stress
• Implement stress management and meaningful activities daily, have a routine
• Write a self-check list and strategies to manage them
• When early warning signs are evident, consider using a buddy system (having a supportive friend/ peer accompany the person to social events/ places
• Identify communication strategies to manage situations for challenges: statements that facilitate communicating about own/ other’s boundaries

This requires practice, so some examples are: 
• The right to say ‘no’: 
1. What are my lists of interactions/ topics that I find uncomfortable to assert? 
2. What reduces my sense of freedom/ confidence to say ‘no’ and what are the consequences for me/ others?
3. What can be done about it (eg: practicing statements asserting boundaries)? 
• Take care of own needs and not prioritising others needs to the detriment of the self:
1. What is my list of daily needs (ie: how is my balance of emotional energy maintained so I can be at my best)? 
2. What stops me from taking care of my needs and what are the consequences for me/ others?
3. What can be done about it (eg: creating action plans)? 
• Identifying likes and dislikes:
1. What are my lists of likes/ dislikes (eg: favourite food, favourite movies, music, places, people etc)? 
2. What stops me from engaging with as many of my likes daily as possible and what are the consequences for me/ others?
3. What can be done about increasing my engagement with my likes (eg: action plans, including with other people)? 
• Identify feelings, beliefs and perspectives and assess and address them:
1. What are my lists of common daily feelings, beliefs and perspectives? 
2. What reduces my ability to identify and ‘tune in’ to my feelings, beliefs and perspectives daily and what are the consequences for me/ others?
3. What can be done about it (eg: planning to ‘tune in’ at specific times of the day)? 
• Facilitate respectful, healthy relationships: (NB: safety first: always do what you need to, to keep yourself safe)
1. What are my lists of relationship values, preferences, boundaries, needs and ‘deal breakers’? 
2. What reduces my ability to communicate about and assert my relationship values, preferences, boundaries, needs and ‘deal breakers’ and what are the consequences for me/ others?
3. What can be done about it (eg: planning to engage in relationship strengthening/ meaningful activities and plan times to have fun, ‘tune in’ to my friends/ loved ones at specific times of the day/ week/ month/ year)? 
• Power balance and imbalance: (NB: safety first)
1. What areas of my life/ my relationships have a healthy/ inappropriate balance of power? 
2. What reduces my ability to communicate about and assert my rights/ preferences/ needs and ‘deal breakers’ and what are the consequences for me/ others?
3. What can be done about it (eg: planning to name issues the next time they need addressing or sooner, communicate rights/ preferences/ needs and what is the likelihood of a positive result, is that result likely to be enough/ worth the effort?
Ability to empathise and be emotionally intimate:
1. What are my lists of valued relationships and the needs of the people in them? 
2. What reduces my ability to empathise/ be emotionally intimate and what are the consequences for me/ others?
3. What can be done about it (eg: stress/ anxiety management strategies/ how do I re-invigorate myself if I need to/ what is the best time of the day for me to be present and emotionally intimate)? 
Remain focused on and concentrate on the present:
1. What are my strategies to remain focused on and concentrate on the present? 
2. What reduces my ability to remain focused on and concentrate on the present and what are the consequences for me?
3. What can be done about it (eg: stress management/ plans to note and then address issues that distract me/ strategies to ‘ground’ me/ refocus)? 
Effectively maintain value-based choices regardless of peer pressure:
1. What is my lists of value-based choices and the people who challenge them? 
2. What reduces my ability to assert my value-based choices and what are the consequences for me/ others?
3. What can be done about it (eg: if appropriate, practice calmly and firmly communicating my right to make choices for myself, respectfully acknowledging the other persons value to me, their desire to assist me to be my best and their equivalent right to their own choices)? 
• Learn from mistakes:
1. What are the lists of mistakes that trouble me, that aren’t resolved? 
2. What reduces my ability to empathise with myself/ process and learn from my mistakes/ let go of them and what are the consequences for me/ others?
3. What can be done about it (eg: discuss/ write about/ forgive myself/ make amends)? (Friedman and Boumil, 1995)

Boundary awareness includes the ability to identify an issue. As human beings, we are relational so having a framework that can identify or ‘name’ positive and problematic qualities can be helpful. Awareness of destructive processes and types of power — especially in interpersonal relationships — are helpful to be able to identify.

Maintaining healthy, supportive, reciprocal relationships with self, others and the community that include: unconditional positive regard, congruence and accurate empathy; and do not include: ‘the four destructive processes, including criticism, defensiveness, contempt, stonewalling (listener withdrawal), and belligerence (provocative challenges of the (person’s) power and authority)’. These predict the destruction of a relationship (Gottman, 1994; Gottman et al., 1998). Blame is equally unhelpful. Anger need not be corrosive. However, when anger contains vindictiveness and contempt, it can have a corrosive effect. Cohan and Bradbury (1997).

William Glasser’s Choice Theory states that five innate needs drive behaviour: survival, love and belonging, power, freedom and fun. Behaviour is understood to be mostly consciously chosen, (except when unresolved trauma becomes entrenched and remains unresolved as this affects the person in all areas of life, including relationships). Healthy relationships involve ‘caring habits’ rather than ‘deadly habits’:
• Supporting vs. Criticizing
• Encouraging vs. Blaming
• Listening vs. Complaining
• Accepting vs. Nagging
• Trusting vs. Threatening
• Respecting vs. Punishing
• Negotiating differences vs. ‘bribing’ to control
(Glasser, W., (2013)

The Sociological understanding of ‘power’ is having the ability to meet needs and access resources within society. This may help to name the types of power:

Power in society includes:
Legitimate or positional power: can be in context of roles or systems, including the governmental system for coordinating society, including in relation to justice and authority
Referent power: the use of interpersonal skills to attract others and inspire loyalty. This can also relate to loyalty to a country. The ethical integrity of the individual inspiring the loyalty is essential, as power abuse can occur. 
Expert power: skills or expertise that is needed, admired or valued. This power is usually limited to the field of expertise.
Reward power: the power to provide a valued reward on another.
Coercive power: the power to threaten and punish (this is often enacted without the right to and there are countless decades of research evidencing that punishment does not work to achieve prosocial results).

Power in interpersonal relationships include:
• Equal or unequal
: this may be equal or unequal without power abuse, for example, in certain eras, roles were accepted to be strictly defined by gender. Individual relationships may be/ may have been negotiated and defined by consenting partners.
Power abuse: this can be bullying, when the bully does not have delegated authority to exert a specific power or control over another person. Power abuse can be family and domestic violence. In abusive relationships, the perpetrator will use various power and control tactics including physical, emotional, sexual, spiritual, legal, financial and verbal threats to control the other person.

Power tactics used to influence others include: 
• Soft and hard tactics
: soft tactics utilize the relationship as the foundation for influence and hard tactics involve threats, punishment to force outcomes. 
Rational and non-rational tactics: rational tactics involve reasoning and logic to persuade others and non-rational tactics involve emotional manipulation and misinformation
Unilateral and bilateral tactics: unilateral tactics include disengagement and withdrawal, only requiring an individual’s choice and do not require another’s participation/ consent of the tactic to be enacted and bilateral tactics include collaboration and negotiation, involving others (May, R. (1972) Power and innocence. New York, NY: Dell publishing Co. ‘Relationships, Toward New Community’ and ‘The Meaning of Power’) (Smail, D. (1983) The origins of unhappiness. London, UK: Harper Collins Publishers. ‘Bodies and Worlds the Field of Power’)

Affect awareness and regulation:
Identifying and managing emotions can be frightening because many societies do not facilitate the valuing, expression or engagement with emotions and so often they are avoided and derided which reduces the skills for managing them. Practicing stress management, relaxation and self-soothing is important before tackling emotions, especially if they have been avoided.

Resources that may be helpful: 
• Feeling wheel (no colour)
https://med.emory.edu/excel/documents/Feeling%20Wheel.pdf 
Feeling wheel with reference and colour http://pathworksohio.com/wp-content/uploads/2014/02/The-Feeling-Wheel-with-reference.pdf

A small list of ‘positive’ or preferred emotions include: joy, gratitude, serenity, interest, hope, pride, amusement, inspiration, awe, love.

A small list of less preferred ‘negative’ emotions include: envy, jealousy, greed, arrogance, resentment, superiority, hate.

My list of ‘deadly’ emotions include: shame, self-hate. This is because we keep these feelings alive, rather than process the experiences, then remember the lesson and grow. Shame is often felt by victims of crime and that internalised sense of responsibility should really only ever sit with the perpetrator of that crime.

Consider the idea of noticing and experiencing emotions (knowing they will pass from the present), as opposed to reacting to them or fearing them. Identify some strategies to express and process them and increase the experience of positive emotions. Positive emotions and attitudes are known to impact on recovery following surgery. Negative emotions including stress are understood to increase inflammation, therefore, identifying them, expressing them safely, processing them and releasing them is important.

Resources that may be helpful:
Meta-emotion and couples’ therapy John Gottman https://lifespanlearn.org/documents/Gottman-meta-emotion.pdf 
Robert Plutchik’s Psychoevolutionary Theory of Basic Emotions http://www.adliterate.com/archives/Plutchik.emotion.theorie.POSTER.pdf 
Jane Mc Campbell Complex trauma relief TFT https://www.youtube.com/watch?v=3A_DK50fUqc 
Dr Mary Cowley Trauma relief TFT https://www.youtube.com/watch?v=g8nF8rdDxGs

The ‘Focusing Process’ from the ‘Win Win’ method of conflict resolution can assist in the process of identifying emotions:
• Step 1: Relax: do a breathing or visualisation exercise, go for a walk. The idea is to be calmer 
• Step 2: Feel for the problem
• Step 3: Attend to the core of the uncomfortable feeling

Pose this question, without responding: ‘What’s really the matter?’: the intention is to seek the meaning attributed to the experience that is behind the feeling, leading to deeper self-awareness, processing and wisdom
Step 4: Find the right label for the feeling
• Step 5: Allow a little time to experience any body-shift.
• Step 6: Another round starting from Step 3.
(Cornelius, H., Faire, S., Cornelius, E., 2006 Everyone Can Win: responding to conflict constructively)

Assess the levels of feelings using Joseph Wolpe’s (1969) Subjective Unit of Distress (SUD) rating scale to measure individual distress levels 0–10: ‘0’ is the best a person can feel and ‘10’ is the worst a person can feel:
• To express the level to which a person feels challenged by their feelings or experiences 
• To express the intensity of the feeling
• To describe pain
• To empower a person to quantify their trauma and express it 
• To map shifts in feelings
• To identify the need for action to address the distress
• To notice any patterns: differences in distress at different times, facilitating hope and perseverance
• To be used strategically during the day, to notice when distress may occur to identify triggers or other contributing factors, escalation and strategies to manage them and to identify when it is less evident, to identify and increase protective factors

Expressing emotions verbally or in writing can benefit from a structure to guide processing:
‘I feel (…feeling word…)’ (context, if needed). 
‘The effect of the experience on me is… (values, beliefs, boundary violation etc)’. 
‘I feel (…feeling word…) because (…reason/ cause…) (…meaning/ effect…)’.

Writing a summary list about the experience can clarify what needs to be done to address it:
• Facts, details 
• Perceptions of the challenge 
• Things done to address the challenge 
• Things not done to address the challenge 
• Things avoided 
• Expectations met 
• Expectations not met 
• Strengths 
• Consequences of the experience in the present and if nothing changes 
• Future implications
(Kranz, D., Sanders, V., 2006)

Navigating the impact of thoughts on feeling and behaviour can also benefit from a structure. One way is using Positive Psychology to identify an alternative way to view the situation:
Belief of challenging experience viewed from an optimistic perspective:
• (Optimistic) temporary perspective (cause is transient): 
• (Optimistic) specific perspective (cause will affect few future situations: it is contained to this experience): 
• (Optimistic) impersonal perspective/ behavioural self-blame (behavioural and therefore changeable ‘issue’ that can be addressed by increasing skills, etc):

Belief of challenging experience viewed from a pessimistic perspective:
• (Pessimistic) permanent perspective (cause will continue):
• (Pessimistic) pervasive perspective (cause will affect many situations): 
• Pessimistic) personal perspective/ characterological self-blame (personally ‘flawed’):

Cognitive distortions can be identified (then disputed) using Aaron Beck’s list of Cognitive Distortions (Beck et al. 1979, Beck and Weishaar 1995, Dattilio and Freeman 1992):
• Arbitrary Inferences (catastrophizing)
Selective Abstractions (thin conclusions, lacking evidence or contradictory evidence) including emotional reasoning (eg: having a feeling, assuming there must be a reason/ cause for it) and ‘mind reading’ (eg: assuming people think or feel negatively about you without solid evidence)
Over-Generalizations (especially pessimistic ones)
Magnification and Minimization (distorting)
Personalizations 
Labelling and Mislabelling (selectively, dysphemistically equating self with ‘flaws’ and past mistakes)
Polarized Thinking (perceiving all through black and white terms, good/ bad, right/ wrong) (Corey, G. (2001) Theory and Practice of Counselling Psychotherapy 6th ed)

I hope, that this was helpful and I am happy to provide more information.

Thank you for reading.