This post is for physicians looking to bring Ontario Medical Association psychotherapy and mental health care teaching to communities outside Toronto.
This topic remains a huge challenge, and I'm told continues to draw a fair amount of attention and terse communications.
I'm sorry to say that - three years into my tenure as education chairman - I still have not found, or heard a good solution to this problem.
Here's the rub.
It's been a great challenge and very time-consuming just to run the program in Toronto. And the kind of program I have in mind is as much about people getting together and sharing as it is about anything else. The practice of psychotherapy is challenging in that it is relatively isolating, something that makes it more dangerous for both clinicians and the patients they treat. So the emphasis of this series has been on allowing us to be seen and heard by our colleagues, and to find a geographical place where we can mutually support one another.
There is lots of great teaching on the web. So, although I do imagine one day that we will be videotaping our talks, what I imagine this will add of most value will be a chance in interact by video-conferencing. The technology is already available to film a talk in Toronto, have an audience in place in St. Catherine's or Timmins (for example) and have the audience ask questions at the end of the talk to the Toronto speaker.
This is what I know I don't want. The talks that are easiest to transport out of Toronto are often the same old topics we've been hearing over and over again. I took on this role as education chairman because of my concerns about the way we're being taught already - too much emphasis on psychopharmacology and on the cognitive (although both are important, they lose a great deal when they purport to be the cornerstone of mental health treatments, which - in my view are much more centered on human relationship, mindfulness, an understanding and application of trauma and attachment theory and a view of the body, brain and mind as a larger whole). So I don't want to start exporting the kind of talks that will just create a kind of two-tiered system where Toronto gets the best, most thought-provoking talks and Timmins and St. Catherine's get the tired old song.
I also don't want to promote our talks being videotaped, so that physicians watch them alone at home, although I admit that wouldn't be the worst thing in the world. I know colleagues claim to be busy, but psychotherapy is a field where there can be no good excuse for too much isolation.
So, we're looking for local and regional champions to help with our endeavours. This might include:
1.) Those willing to spend time investigating and arranging videotaping and video-conferencing of our education series.
2.) Those willing to engage in community building in areas outside of Toronto. From there, these local champions can find local speakers who offer the same exciting new ideas we are exploring in this blog, or who can find ways to bring local physicians and other mental health care providers to lead and facilitate discussion groups.
3.) Those willing to engage in creating conferences that combine regional experts with out of town speakers. For instance, I know that an Ottawa group is working with some Toronto colleagues to create a state of the art PTSD conference, focussing on primary care treatment for military veterans.
4.) Those willing to create funding and grant proposals to expand the scope of our teaching series.
Anyway, let me know your ideas. At the same time, please be aware that your ideas will only come to fruition when they come with a willingness to play a role in the huge efforts involved in running a unique stand-alone education series.
I look forward to hearing from colleagues. I thank you for your patience.
Wednesday 28 May 2014
IMPACT - Teaching Trauma-Informed Self-Defence and Assertiveness
Hello from Boston, where I'll be spending the next few days.
Leaving behind a sweltering late-May Toronto (and my warm clothes as well), I arrived yesterday to cold, wind and drizzle on the northeastern American seaboard.
I'm at the 25th Annual International Trauma Conference, hosted by the world-renowned Boston Trauma Center and co-sponsored by The Meadows and the National Child Traumatic Stress Network. It portends to be somewhat of a Woodstock for the trauma world, with many of the world's most famous trauma clinicians and researchers coming together to celebrate a quarter century of growth and struggle
Today was a pre-conference day and I attended a full day workshop on IMPACT, a discipline founded in 1971, with a mission to promote safety and realistic self-defence skills, without the need to master a martial art.
A ways back in my trauma training, I came across the term "Sitting Duck Syndrome", coined by Richard Kluft, a psychiatrist and pioneer in the diagnosis and treatment of dissociative identity disorder. Kluft described victims of childhood trauma who went on to be re-victimized in adult life, not only by family members and perpetrating strangers, but also by people in the mental health care field.
Those of us who practice full-time psychotherapy see this frequently in our patient population - in fact, the tendency to re-victimization is one of the ways we start to suspect a history of attachment failure and subsequent traumatization. And over the years, I've found the whole issue of safety to be more and more central to the care I provide. Often, during intake, I am already asking myself: Is this patient safe? What is his or her posture saying? Do I see evidence of immobilizing responses (freeze or feigned death/dissociation) or of truncated mobilizing defences (like an inability to fully extend the wrist in making a boundary motion while relating a time when a boundary would have been adaptive)? In the long term, I find it hard to accept sending a patient back into the world without the ability to defend themselves; this certainly seems as important as any number of other treatment goals.
Today was mostly spent practicing self-defence. That meant some time with PowerPoint, and a lot of time on the mat (or hotel carpeting in this case). Only one of the attendees had previous martial arts training, which was in no way necessary for the workshop.
Martial arts and self-defence are one of the least studied aspects in medical research, despite the fact that we live in an increasingly dangerous world. And there are many myths abounding about how to best protect ourselves. We tend not to think about this until it is a loved one or a patient, or even ourselves that is victimized.
The IMPACT work provides realistic simulations and a chance to react to them. A core set of verbal de-escalation and boundary skills are taught, as well as effective self-defence tactics that can be employed during an assault. These maneuvers are taught in a way that encourages encoding in muscle memory, so that they may be employed long after they were taught. The training also covers "adrenaline-management skills", which are certainly necessary for all our trauma and highly stressed patients, and also extremely useful for ourselves.
Meg Stone, the main instructor today, noted that trauma victims often come to the work feeling they are unworthy of safety and of fighting for themselves. By learning to defend themselves they often come to re-evaluate these traumatic beliefs and learn that they are worthy struggling for dignity, healing and the desire for a better life, away from those who abuse and exploit them.
They often also learn new postures and responses that, without any further thought involved, remove the somatic cues that are attractive to perpetrators. While learning how to respond to attempted rape (an interesting exercise for me to engage in), I liked the fact that the process was termed a Reversal rather than as something cold and dry like a tactic to oppose a sexual assault.
Meg was assisted by Alex, who works in both childhood education and in security services. Alex, a man whose demeanor offered a fascinating alchemy of tenderness and street toughness, was already much larger than Meg. Once he suited up in protective body armour, including a large headpiece that left him looking a little like a Judoon soldier from Doctor Who, the size mismatch appeared even greater. Though small in body, Meg was large in presence and taught us through example to meet our attacker with the intensity and speed that would be necessary for a real-life assault.
It's nice to come across knowledge that is as much based on "street-based research" as on collected data. IMPACT work has been shown to decrease hyperarousal/hypervigilance and shame in trauma survivors, while helping to build confidence. Who knew that self-defence can be healing? And on so many levels.
IMPACT Boston teaches clients from age 7 to age 80 and teaches across a wide range of populations. They do a lot of teaching with special needs students, including skills to help them set healthy boundaries with caregivers and custodial staff.
Meg will travel to teach, and Alex has taught as far away as South Africa. Check out their website at http://www.impactboston.com/index.html. There are some videos on the website; a good chance to see Meg in action and to see the kind of encouragement and mutual support she brings to her classes . If you are involved in any kind of mental health program, ask yourself if it is worth bringing the IMPACT team to your clinic or organization for a day or weekend long workshop for staff or for patients.
One side benefit for me today is that I feel more in my body as the main conference approaches, but - more importantly - I also feel safer in the ever-changing world. I will continue to practice the skills I learned today some, but most of the laying down of new pathways and consciousness has already been done.
Now is a good time to ask yourself what you as a physician or mental health clinician are doing to provide skills to keep your patients safe and to create healthy boundaries. What can you possibly add to the mix, after reading this entry and reflecting on the topic of self-defence and mindbody health?
Keep in touch with our teaching programs which aim to be trauma-informed, and to provide the kind of programming that relies as much on street cred and embodied awareness as they do on new advances in the field of psychotherapy.
Leaving behind a sweltering late-May Toronto (and my warm clothes as well), I arrived yesterday to cold, wind and drizzle on the northeastern American seaboard.
I'm at the 25th Annual International Trauma Conference, hosted by the world-renowned Boston Trauma Center and co-sponsored by The Meadows and the National Child Traumatic Stress Network. It portends to be somewhat of a Woodstock for the trauma world, with many of the world's most famous trauma clinicians and researchers coming together to celebrate a quarter century of growth and struggle
Today was a pre-conference day and I attended a full day workshop on IMPACT, a discipline founded in 1971, with a mission to promote safety and realistic self-defence skills, without the need to master a martial art.
A ways back in my trauma training, I came across the term "Sitting Duck Syndrome", coined by Richard Kluft, a psychiatrist and pioneer in the diagnosis and treatment of dissociative identity disorder. Kluft described victims of childhood trauma who went on to be re-victimized in adult life, not only by family members and perpetrating strangers, but also by people in the mental health care field.
Those of us who practice full-time psychotherapy see this frequently in our patient population - in fact, the tendency to re-victimization is one of the ways we start to suspect a history of attachment failure and subsequent traumatization. And over the years, I've found the whole issue of safety to be more and more central to the care I provide. Often, during intake, I am already asking myself: Is this patient safe? What is his or her posture saying? Do I see evidence of immobilizing responses (freeze or feigned death/dissociation) or of truncated mobilizing defences (like an inability to fully extend the wrist in making a boundary motion while relating a time when a boundary would have been adaptive)? In the long term, I find it hard to accept sending a patient back into the world without the ability to defend themselves; this certainly seems as important as any number of other treatment goals.
Today was mostly spent practicing self-defence. That meant some time with PowerPoint, and a lot of time on the mat (or hotel carpeting in this case). Only one of the attendees had previous martial arts training, which was in no way necessary for the workshop.
Martial arts and self-defence are one of the least studied aspects in medical research, despite the fact that we live in an increasingly dangerous world. And there are many myths abounding about how to best protect ourselves. We tend not to think about this until it is a loved one or a patient, or even ourselves that is victimized.
The IMPACT work provides realistic simulations and a chance to react to them. A core set of verbal de-escalation and boundary skills are taught, as well as effective self-defence tactics that can be employed during an assault. These maneuvers are taught in a way that encourages encoding in muscle memory, so that they may be employed long after they were taught. The training also covers "adrenaline-management skills", which are certainly necessary for all our trauma and highly stressed patients, and also extremely useful for ourselves.
Meg Stone, the main instructor today, noted that trauma victims often come to the work feeling they are unworthy of safety and of fighting for themselves. By learning to defend themselves they often come to re-evaluate these traumatic beliefs and learn that they are worthy struggling for dignity, healing and the desire for a better life, away from those who abuse and exploit them.
They often also learn new postures and responses that, without any further thought involved, remove the somatic cues that are attractive to perpetrators. While learning how to respond to attempted rape (an interesting exercise for me to engage in), I liked the fact that the process was termed a Reversal rather than as something cold and dry like a tactic to oppose a sexual assault.
Meg was assisted by Alex, who works in both childhood education and in security services. Alex, a man whose demeanor offered a fascinating alchemy of tenderness and street toughness, was already much larger than Meg. Once he suited up in protective body armour, including a large headpiece that left him looking a little like a Judoon soldier from Doctor Who, the size mismatch appeared even greater. Though small in body, Meg was large in presence and taught us through example to meet our attacker with the intensity and speed that would be necessary for a real-life assault.
It's nice to come across knowledge that is as much based on "street-based research" as on collected data. IMPACT work has been shown to decrease hyperarousal/hypervigilance and shame in trauma survivors, while helping to build confidence. Who knew that self-defence can be healing? And on so many levels.
IMPACT Boston teaches clients from age 7 to age 80 and teaches across a wide range of populations. They do a lot of teaching with special needs students, including skills to help them set healthy boundaries with caregivers and custodial staff.
Meg will travel to teach, and Alex has taught as far away as South Africa. Check out their website at http://www.impactboston.com/index.html. There are some videos on the website; a good chance to see Meg in action and to see the kind of encouragement and mutual support she brings to her classes . If you are involved in any kind of mental health program, ask yourself if it is worth bringing the IMPACT team to your clinic or organization for a day or weekend long workshop for staff or for patients.
One side benefit for me today is that I feel more in my body as the main conference approaches, but - more importantly - I also feel safer in the ever-changing world. I will continue to practice the skills I learned today some, but most of the laying down of new pathways and consciousness has already been done.
Now is a good time to ask yourself what you as a physician or mental health clinician are doing to provide skills to keep your patients safe and to create healthy boundaries. What can you possibly add to the mix, after reading this entry and reflecting on the topic of self-defence and mindbody health?
Keep in touch with our teaching programs which aim to be trauma-informed, and to provide the kind of programming that relies as much on street cred and embodied awareness as they do on new advances in the field of psychotherapy.
Monday 19 May 2014
Pivotal Moments in Psychotherapy - Part 1.
During the last couple of weeks, I've been thinking about defining, or pivotal moments in psychotherapy.
At the end of April, I attended a conference entitled: Interpersonal Neurobiology with Innovative Therapeutic Practices, organized by the Hincks-Dellcrest Centre in Toronto.
The conference took place over three days. The first day featured Dr Dan Siegel speaking to a sold-out audience about the basic principles of Mindsight and Interpersonal Neurobiology. I won't review the subject matter of his talk in detail here today. Many readers will already be familiar with his work, and more undoubtedly will be over the years to come. One thing I have to say about Dr Dan is that he knows how to attract a big audience, although I think he does this less by guile than by mastery of his subject matter. His emphasis on the "neurobiology of we", revealing us as deeply social beings, and his clear explanations of mind, neuroscience and the importance of integration, make his work accessible and relevant to mental health practitioners, spiritual seekers and the general population all at once. I was pleased to meet many colleagues on this full day presentation - I think that at one point I counted fifteen GP psychotherapists in the theatre.
The next two days included lectures and various workshops which aimed to take the theory and practice of interpersonal neurobiology (IPNB) into our daily clinical work.
I was excited to sign up for one of the workshops co-led by Jim Duvall, about whom - over the years - I've heard so many good things said. The workshop was evocatively entitled: Hemishphere Dancing: Inviting Pivotal Moments, Streams of Consciousness and Transport in Narrative Conversations. I especially liked the term hemisphere dancing. I'm primarily trained as a somatic psychotherapist, so for me, the idea of two parts of the brain dancing together has an almost kinaesthetic feel to it.
The idea of hemisphere dancing, based on IPNB theory, is that the therapist, while witnessing the unfolding narrative, assists the patient in moving back and forth between fact and feeling, thought and sensation, in such a way that the unfolding process becomes a more whole brain process.
I know, intuitively, and from experience, what a pivotal moment is, or at least resembles, but I do find it somewhat difficult to put into words. So I will leave you with the the description written by Jim Duvall and his co-presenter, Robert Maclellan:
Pivotal moments are those rewarding junctures - the smallest chunk of lived experience that occur in the moment-to-momentness of therapeutic conversations -when a particular question cracks open a door that shines light on possibilities only thinly imagined. Michael White described these moments as "epiphanies that are in harmony with what is precious to people, that is beautiful, that they want to rush toward" (Duvall and Young, 2007). Such pivotal moments, hidden in full view, form associational narratives in which people experience transport and are able to connect with a strong sense of "myself". What makes them stick is how they are responded to in the outside world."
The workshop helped me to gain a clearer understanding of how I "engage and sustain these otherwise fleeting, meaningful experiences", where a smaller story of self momentarily breaks open, leaving the patient exposed to a larger story and to a self-sense more open to new and deeper possibilities.
Here we find brief glints of colour in the narrative of the depressed person, or "sparkles" emerging in an otherwise quiet tale. And here, it is the role of the good therapist to identify these moments and to reflect them back to the patient. Done well, new gifts emerge from ambiguity and uncertainty. Too much certainty on the part of the therapist will actually close the process down, thus robbing the patient of this rich opportunity for change.
Research has shown, over the years, that there is a very brief window of opportunity in making contact with a pivotal moment. The range is between four and ten seconds. The clinical qualities in a therapist that incline them toward identifying and contacting pivotal moments are that they go slow, that they stay mindful and present, and that they utilize imagery and metaphor in their language.
At the pivotal moment, the patient enters what Dan Siegel calls the open plain of possibility. Here, by activating the open areas of the pre-frontal cortex, the possibility of new insights and of bridging connections between different brain regions is potentially infinite.
We wouldn't want to spend too much time in pivotal moments and Dr Siegel correctly notes that good health means the ability to move between evoking certainty in some moments and possibility in others. Both are necessary for a life that allows for wholeness and change.
Jim Duvall, in his talk, quoted Emmanuel Kant, who put it another way:
Concepts without intuitions are empty.
Intuitions without concepts are blind.
In Part 2 of this post, I'm going to give some case examples, one from Jim Duvall and one from my own practice.
In the meantime, why not reflect on your own experience, on your own pivotal moments and the patient pivotal moments you've witnessed and deepened in your own clinical work. Feel free to share one or the other, if it feels right. This may even be a chance to return to a past moment, and to travel even further on the open plain of possibility. Who knows what new experiences and ideas are awaiting you at the wild frontiers of self and other.
At the end of April, I attended a conference entitled: Interpersonal Neurobiology with Innovative Therapeutic Practices, organized by the Hincks-Dellcrest Centre in Toronto.
The conference took place over three days. The first day featured Dr Dan Siegel speaking to a sold-out audience about the basic principles of Mindsight and Interpersonal Neurobiology. I won't review the subject matter of his talk in detail here today. Many readers will already be familiar with his work, and more undoubtedly will be over the years to come. One thing I have to say about Dr Dan is that he knows how to attract a big audience, although I think he does this less by guile than by mastery of his subject matter. His emphasis on the "neurobiology of we", revealing us as deeply social beings, and his clear explanations of mind, neuroscience and the importance of integration, make his work accessible and relevant to mental health practitioners, spiritual seekers and the general population all at once. I was pleased to meet many colleagues on this full day presentation - I think that at one point I counted fifteen GP psychotherapists in the theatre.
The next two days included lectures and various workshops which aimed to take the theory and practice of interpersonal neurobiology (IPNB) into our daily clinical work.
I was excited to sign up for one of the workshops co-led by Jim Duvall, about whom - over the years - I've heard so many good things said. The workshop was evocatively entitled: Hemishphere Dancing: Inviting Pivotal Moments, Streams of Consciousness and Transport in Narrative Conversations. I especially liked the term hemisphere dancing. I'm primarily trained as a somatic psychotherapist, so for me, the idea of two parts of the brain dancing together has an almost kinaesthetic feel to it.
The idea of hemisphere dancing, based on IPNB theory, is that the therapist, while witnessing the unfolding narrative, assists the patient in moving back and forth between fact and feeling, thought and sensation, in such a way that the unfolding process becomes a more whole brain process.
I know, intuitively, and from experience, what a pivotal moment is, or at least resembles, but I do find it somewhat difficult to put into words. So I will leave you with the the description written by Jim Duvall and his co-presenter, Robert Maclellan:
Pivotal moments are those rewarding junctures - the smallest chunk of lived experience that occur in the moment-to-momentness of therapeutic conversations -when a particular question cracks open a door that shines light on possibilities only thinly imagined. Michael White described these moments as "epiphanies that are in harmony with what is precious to people, that is beautiful, that they want to rush toward" (Duvall and Young, 2007). Such pivotal moments, hidden in full view, form associational narratives in which people experience transport and are able to connect with a strong sense of "myself". What makes them stick is how they are responded to in the outside world."
The workshop helped me to gain a clearer understanding of how I "engage and sustain these otherwise fleeting, meaningful experiences", where a smaller story of self momentarily breaks open, leaving the patient exposed to a larger story and to a self-sense more open to new and deeper possibilities.
Here we find brief glints of colour in the narrative of the depressed person, or "sparkles" emerging in an otherwise quiet tale. And here, it is the role of the good therapist to identify these moments and to reflect them back to the patient. Done well, new gifts emerge from ambiguity and uncertainty. Too much certainty on the part of the therapist will actually close the process down, thus robbing the patient of this rich opportunity for change.
Research has shown, over the years, that there is a very brief window of opportunity in making contact with a pivotal moment. The range is between four and ten seconds. The clinical qualities in a therapist that incline them toward identifying and contacting pivotal moments are that they go slow, that they stay mindful and present, and that they utilize imagery and metaphor in their language.
At the pivotal moment, the patient enters what Dan Siegel calls the open plain of possibility. Here, by activating the open areas of the pre-frontal cortex, the possibility of new insights and of bridging connections between different brain regions is potentially infinite.
We wouldn't want to spend too much time in pivotal moments and Dr Siegel correctly notes that good health means the ability to move between evoking certainty in some moments and possibility in others. Both are necessary for a life that allows for wholeness and change.
Jim Duvall, in his talk, quoted Emmanuel Kant, who put it another way:
Concepts without intuitions are empty.
Intuitions without concepts are blind.
In Part 2 of this post, I'm going to give some case examples, one from Jim Duvall and one from my own practice.
In the meantime, why not reflect on your own experience, on your own pivotal moments and the patient pivotal moments you've witnessed and deepened in your own clinical work. Feel free to share one or the other, if it feels right. This may even be a chance to return to a past moment, and to travel even further on the open plain of possibility. Who knows what new experiences and ideas are awaiting you at the wild frontiers of self and other.
Wednesday 7 May 2014
ANPs and EPs
Here's a nice little promo video from Confer UK, just under two minutes long.
http://www.confer.uk.com/module-promo-new.html
I was first exposed to Confer in 2007, when I went to their Psychological Trauma and the Body Conference, in London.
I was pretty new and under-exposed to the field at the time.
One of my reasons for attending was to see Pat Ogden speak, in preparation for my first level of sensorimotor psychotherapy training, which started shortly after the conference.
A few of the speakers on the promo video, such as Allan Schore, Felicity de Zulueta and Valerie Sinason also spoke.
In recent correspondence with Confer, they informed me that they have a group rate for The Nature of Trauma and Dissociation online training.
This is the kind of education available to colleagues living just about everywhere, and it can be an option for groups of physicians practicing psychotherapy who cannot always meet in person - of course it's even more ideal for those that can.
I do like this series because there are just so many inspiring and inspired teachers participating in the project.
Before you finish, stop the video at about 0:55, and you'll see a complicated diagram next to the photo of Onno van der Hart. I've actually used this picture as a teaching aid, to help Complex PTSD patients (about 30% of any given mental health population) understand the play and inter-relatedness of their EPs and ANPs.
Stay tuned, because in a soon to appear post, I will discuss the film The Perks of Being a Wallflower, an autobiographical movie in which a fight EP emerges during a dissociative episode.
http://www.confer.uk.com/module-promo-new.html
I was first exposed to Confer in 2007, when I went to their Psychological Trauma and the Body Conference, in London.
I was pretty new and under-exposed to the field at the time.
One of my reasons for attending was to see Pat Ogden speak, in preparation for my first level of sensorimotor psychotherapy training, which started shortly after the conference.
A few of the speakers on the promo video, such as Allan Schore, Felicity de Zulueta and Valerie Sinason also spoke.
In recent correspondence with Confer, they informed me that they have a group rate for The Nature of Trauma and Dissociation online training.
This is the kind of education available to colleagues living just about everywhere, and it can be an option for groups of physicians practicing psychotherapy who cannot always meet in person - of course it's even more ideal for those that can.
I do like this series because there are just so many inspiring and inspired teachers participating in the project.
Before you finish, stop the video at about 0:55, and you'll see a complicated diagram next to the photo of Onno van der Hart. I've actually used this picture as a teaching aid, to help Complex PTSD patients (about 30% of any given mental health population) understand the play and inter-relatedness of their EPs and ANPs.
Stay tuned, because in a soon to appear post, I will discuss the film The Perks of Being a Wallflower, an autobiographical movie in which a fight EP emerges during a dissociative episode.
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