1. Distress Reduction
Techniques
2007
Forrest James and Chris Lobsinger

2. Program
 Support vs. Exposure?
Horowitz
Terr’s
 When remembering is not advisable
 Distress reduction and affect
regulation.
 Watch Your breathing

3.  Grounding and containment
 Five senses
 Where are my edges
 Strength and balance
 Sleep hygiene
 Nightmare protocol
 Containing Writing Technique
 Flashback protocol
Program

4. Horowitz Map
Traumatic experience
1. Outcry Phase
2.Denial Phase
3.Intrusive Phase
4. Working through Phase

5. Terr’s Typing
 Type I: Single Event
Less need to provide frame Direct work with trauma
 Type II: Repeatedly Traumatized
Less need to provide frame Direct work with trauma
Type IIA: Stable Background Ability to Separate
Traumas Less work on frame Direct work on trauma
I = Single event , II = Multiple events, A =Stable background,
B =Unstable background ,R = Resilience NR = No resilience

6.  Type IIB: Unable to separate traumas
Build Frame before working with trauma
 Type IIBR: Unstable but resilient
Reacquaint client with forgotten or
under utilized resources
 Type BNR: Unstable and little resilience
Building resources is the therapy
I =Single event, II Multiple events, A =Stable background, B
=Unstable background, R =Resilience NR = No resilience

7. When remembering is not advisable
 If you have not established a strong
relationship.
 If the client is not familiar with therapy.
 If the client is engaging in out of control
addictive behavior, self mutilation, in
danger of suicide, or homicide.
 If the client is under current life stressors
Mastsakis, Aphrodite, Post Traumatic Stress Disorder, A complete treatment
Guide, New harbinger Publications ,Inc 1994

8.  If the client does not have a support system
other than your self
 If the client is currently in the intrusive/
hypervigilant phase of PTSD
 If the client has stated she or he does not
wish to remember the trauma
 If the client is suffering a psychotic episode or
is manifesting psychotic symptoms.
 If the client begins to talk about trauma
during the last few minutes of a session
 If the client has forgotten the memories they
have just retrieved In beginning of the
session.

9. Culturally Sensitive Use of
Techniques
 Relationship proceeds technique
 Shared world view/ rational for technique.
 Client expectancy needs to raised
 Techniques may need to be adapted for the
clients culture.
 Use of common factors model

10. Distress Reduction and Affect
Regulation
 It is important to help clients to feel more
in control of there affect and to help them
regulate and control their negative affect.
 To reduce suffering
 To reduce the use of other strategies such
as alcohol/drugs, dissociation, and
excessive avoidance which inhibit
recovery.
John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation and
treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

11. Two categories of distress and affect
reduction.
 1. Interventions for acute
destabilizing emotions.
 2. Interventions that improve
negative emotional regulating
 John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation and
treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

12. Grounding techniques
 Grounding techniques used when
 Sudden panic
 Flashbacks
 Intrusive thoughts
 Intrusive memories

13. Grounding principals
 Focus the client attention on the here and
now which is safe and predictable.
 Can be useful in emergency situational
 Be careful not to stigmatize the client by
over dramatizing the situation

14. Basic Grounding
1. Focus the client attention onto the
therapist and the therapy as
opposed to internal processes.
 Shift closer to the client
 Speak clearly
 Be careful with touch/verbal
interventions are recommended.

15. 2. Ask the client to describe his or her internal
experience ask them to label there internal
experience not in detail
3.Orient the client to immediate external
environment.
Use their name______________
You are here_________safe in this room.
This is the present not the past.
Focus of the present not the past.

16.  4. If indicated focus on breathing
methods if needed.
 5. Repeat steps 2 and 3 and assess the
clients ability and willingness to
continue.
 John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms
Evaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

17. Practice Grounding
 In groups of three CTO client,
Therapist observer.
 Role play a distressed client,
Therapist while the observer help by
prompting the therapist from the
notes.

18. Chronic Dysregulation
 When posttraumatic arousal and
dysphoria are too intense they
interfere with treatment and
recovery.
 Medication may be indicated but
they are not sufficient without
trauma processing.

19. Relaxation training
There are two main approaches to
relaxation training:
1.Breathing
2.Progressive relaxation: (clenching
and relaxing)
 Relaxation techniques are not likely
to be helpful isolation from trauma
processing.
John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to
symptoms Evaluation and treatment Sage Publications Inc 2006 Thousand Oaks
London. New Dehi

20. General Affect Regulation
 Identifying and discriminating emotions
 When people are over aroused the ability to
identify and label emotions can be lost and
the client can perceive their internal state as
chaotic and unpredictable.
 Asking the client to name their feelings
 Encouraging the client to know and label
their feelings should be an ongoing process.
John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation and
treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

21. Identifying and countering thoughts that
antecedent intrusive experiences
 The trigger
 The memory
 The thought that came with the
memory
 The current feeling
 Identify the negative cognition and a
suitable counter cognition.
John Briere Phd & Catherine Scott MD Principals of Trauma Therapy, a guide to symptoms
Evaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehli

22. Practice
 In groups of three CTO Client, Therapist
Observer.
 Take turns remembering a time when
something triggered a memory for you.
 Identify the trigger , the memory, the
thought and a countering thought.
 Don’t use any memory that is highly
traumatic

23. Trigger Awareness and Intervention
Identify the thought feeling or sensation as
posttraumatic
 Does the TFS make sense given my current
context?
 Are these TFS to intense based on the current
context?
 Does this TFS carry with it memories of the past?
 Am I experiencing an altered state of awareness?
 is this a situation where I usually get triggered ?
John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms Evaluation and
treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

24.  Evaluate the stimuli present in the
triggering environment and identify
which is trauma reminiscent. “Find
the trigger”
 Construct an adaptive strategy
 Intentional avoidance
 Analyse trigging experience
 Increase supportive systems
 Positive Self talk
 Relaxation, breathing
 Strategic distraction
 John Briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms
Evaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

25. Resistance to Tension Reducing
Behaviours
 TRB’S self mutilation, impulsive
sexual behaviour, binging,
purging,
 hold off as long as possible
 doing it to the minimum (only)
 Take a firm stand against harmful
TRBS
 Controlling TRBS should not
simply be seen as stopping bad
behaviours but learning affect
regulation.

26.  Affect Regulation is Learned During
Trauma Processing.
 Affect tolerance is learned through
controlled non overwhelming exposure
and the increased ability to self sooth.
 John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a guide to symptoms
Evaluation and treatment Sage Publications Inc 2006 Thousand Oaks London. New Dehi

27. Watching Your Breathing
 Reduces Anxiety
 Improves CO2 balance and reduces
flight and flight response.
 Involves a number of elements
 Can be practiced before it is needed
 Can be practiced in increase
capacity to focused on self

28.  Get comfortable
 Take 3 deep breaths
 Breath into diaphragm
 Breath out through pursed lips to control
flow of air.
 While watching the second hand, second
digits, on a watch. Alternatively count
your pulse.

29.  While watching the second hand/digits,
or counting repeat and relaxing word .
 The goal is to increase the amount of
time it take to exhale the breath. Don’t
hold your breath.
 The can be practice three time a days
until proficient.

30. Practice
 Practice the watch breathing as a
large group.

31. Five Senses
 Start with three deep breaths
 Start from the top down eyes, ears, nose,
mouth feelings, outside, feeling inside.
 Concentrate on one sense at a time.
 Naming slowing and rhythmically what you see,
hear….

32. Zones of Awareness
 Zone 1 Seeing Hearing
 Zone 2 Sensations feeling in body
 Zone 3 Thoughts memories Fantasies self
talk
Complete the sentence” Now I am aware
of….. In each zone for one Min
Rotating through zones.

33. Where are my edges
Rothchild, Babette The Body Remembers Norton 2004
1. Feel your butt on the chair what
temperature is the chair? Is it the
same or different from your butt?
Is the chair hard or soft Is your
butt hard or soft? Can you tell
where your butt ends and the
chair begins?

34. 2. Try to feel your legs on the inside
of your jeans/short/pants. Is the
material smooth or rough? Does it
feel nice against your skin or is it
scratchy? Can you feel your whole
leg along the inside of the cloth or
do some parts disappear?

35. 3. Feel your feet inside your shoes.
Are they warm or cold. Move your
toes around. Is there a lot of
space or a little feel the part of the
shoe that is against the bottom of
your foot. Can you feel the
difference between the shoe and
your foot? Can you feel the bottom
of your foot?

36. Practice
 Each person select one of the
exercises to practice.
 The group will have ten minutes to
practice individually
 Report back to larger group.

37. Sleep Hygiene
 Go to bed when you are sleepy and get
up at the same time. Do not sleep in to
make up sleep, do not take naps.
 Set aside time for problem solving during
the day, not at night.
 Do not lie in bed if you cant sleep get out
of bed and do something distracting but
relaxing.

38.  Do not use alcohol to help you sleep
 Avoid caffeine after 4PM no more then
2cups a day.
 Do not smoke one hour before the sleep.
 Avoid sleeping tablets for long term use.
 Reduce noise in sleeping place
 Ensure darkness
 Ensure body comfort, hunger, warmth,
pain control.

39.  Exercise during the day but not before
bed.
 Create a bed time ritual every night
before you go to bed.
 Be aware of anything that can interfere
with your sleep. E.g. pets, digital clocks…
 Management of Mental Disorders, World Health organization Collaborating center Vol2 Fourth
edition 2004

40. Nightmare protocolBabette Rorhchild 2001
 Today I have been really scared of……
 So I might have a nightmare and wake up
feeling…..
 And my heart might beat fast, and I might be
shacking or crying.
 If that happens I will tell myself is is because I
am remembering….
 Then I will turn on the light and look around my
room and name the thing in the room that I see.
 And I will tell myself that I just had a nightmare
and that …. Is not happening now.

41. Defusing Nightmares
 Keep a pen and paper by the bed
 Write out the dream/nightmare in detail.
 Rewrite the dream with positive ending
 Read the new dream with the positive
ending to your self before bed.

42. Containing Writing Technique
 Combined compartmentalization and exposure.
 Deal with self at the top of page
 Write in same place and time.
 Write only for 5 minutes (use timer)
 Write about disturbing, sad thoughts
 2-3 hours before bed.

43.  Example deal:
I will write for 5 minutes each night
at 700 about some thing
disturbing , or sad on the condition
that if I do this then I will not have
my sleep interrupted or have
intrusive thought during the day.

44. If I have intrusive thought,
feeling or dreams I will say to
my self Not now later. As agree
to. I will write about this for 5
minutes a 7 but not now.

45. Flashback ProtocolBabette Rothchild 2001
 Right now I am feeling…
 and I am sensing in my body…
 Because I am remembering…
 And at the same time, I am now in the
year…
 Here…….. (Name the place)
 and I can see…..
 and so I know…..that ….is not happening
now./anymore

46. Points To Remember
 Exercise
 Here and now
 Body awareness
 Staying with the discomfort
 Not over whelming
 Self soothing
 Connectedness

47. Exercise
 In group of three
 Each member picks an exercise they
would like to practice.
 C.T.O. Client, Therapist Observer
roles.

48. Exercise 1
1. Use Fisher’s Common Factors:
 The therapeutic relationship
 Shared world view
 Client expectations
 Ritual or intervention
to describe how these were involved in
while implementing the technique.

49. Exercise 2
 Use Alliance model (Bond, Goal,
Task) to discuss how development
of bond and goal agreement
supported the task (ie, technique
used).

50. References
 John briere Phd & Cathrine Scott MD Principals of Trauma Therapy, a
guide to symptoms Evaluation and treatment Sage Publications Inc
2006 Thousand Oaks London. New Dehi
 Horowitz. M. Stress Response Syndromes, Aronson New York (1976)
 Rothchild, Babette The Body Remembers Norton 2004 Page 80
 Mastsakis, Aphrodite, Post Traumatic Stress Disorder, A complete
treatment Guide,
New harbinger Publications ,Inc 1994
 Management of Mental Disorders, World Health organization Collaborating center Vol2
Fourth edition 2004