The Oceanside Trauma Center of Daytona Beach will strive to heal clients with potentially serious or persistent trauma related mental illnesses as well as those who are in a state of acute crisis. Our mission is to provide services to trauma survivors through appropriate screening, assessment, and our empirically based clinical interventions. 1. Intake Protocol At Oceanside Trauma, we take pride in our modified Trauma and Drug Use Intake Form (TDUIF) which will be administered to all of our potential clients (Beall, Larry, 2001).
We have found that comorbid issues are highly correlated with most Stress issues, especially our military veterans and believe it’s in our clients’ best interests if we administer an intake protocol that addresses this before we proceed any further. It should be noted that if the client’s answers reflect potential comorbid issues based on our intake questionnaire, one on one interviews are scheduled and decisions are made to get the client immediate help if needed. The self-administered questionnaire covers a wide variety of trauma history as well as potential coping/avoidance techniques.
Minor changes have been made to Larry Beall’s original version, with respect to vocabulary and some questions omitted. Identifying an individual’s trauma exposure history is important because of the serious psychosocial impairments associated with PTSD. We believe after reviewing the intake form with the client, we will have an easier process of deciding what the next step is and how to proceed.
Recently I had the pleasure of reading “Soft Spots” by former Marine Sgt.
Clint Van Winkle.
Throughout the reading numerous examples of PTSD were prevalent as he rendered his account of returning home from his deployment in Iraq. Clint should be commended for not holding back during his internal dialog and this candidness really lets you experience his trauma with a first person perspective. I noted several indications along the way that Clint might be suffering from PTSD. Clint references his internal struggles of returning home with a variety of atypical personality traits. He explains how hyper vigilante he was upon his initial return and it felt like letting his guard down was not an option. Clint was meaner, short tempered, and verall more aggressive. He illustrated his lack of emotional connection to his wife saying, “Hugs were as foreign as walking around without a weapon” (Van Winkle, Clint 2009, p. 30). At one point Clint is in a heated argument with his wife and recounts that “he watched from a far and waited for sanity to return” (Van Winkle, Clint 2009, p. 21-22). When driving around town, he conveyed a sense of immortality. He would look for trouble or a reason to start a fight. Things almost came to a head when he was pulled over for speeding and simply demanded the officer give him a ticket or let him go because he didn’t have time to play games.
His uncontrollable flashbacks were another matter altogether. Clint explained that in many instances, he would start conversations with people who weren’t there, some alive and some dead. Logic seemed to walk a fine line in his daily goings. He would question himself, when recounting personal stories with his friends as specific details were often fabricated or inaccurate. Even reality would begin to bend as at one point his mind elicits a little girl from his deployment who dances around and jumps into a coffin at a funeral. These thoughts and flashbacks are intrusive and definitely unwanted.
Clint visits the hospital numerous times for acute anxiety attacks that trap him in dangerous situations like being buried alive by sand (Van Winkle, Clint 2009). All of the aforementioned examples were horizontally consistent with specific criterion needed from the DSM-IV’s diagnostic criteria for post-traumatic stress disorder (American Psychiatric Association, 2000). Clint was able to meet every criterion with some areas meeting more than need be. As he was deployed overseas for a prolonged period of over six months, it is difficult to judge if his PTSD had delayed onset or not.
At Oceanside Trauma we would use several assessment tools for Mr. Van Winkle including the Clinicians Administered PTSD Scale (CAPS), the Generalized Contentment Scale (GCS), and the Mississippi Scale for combat Related PTSD (M-PTSD). The military PTSD checklist may also be utilized if needed. Each respective assessment was chosen for their unique properties and documented success. The CAPS provides information on both current and lifetime PTSD. It provides a continuous measure of each PTSD symptom along two dimensions: intensity and frequency. Recent studies show that CAPS has become the nstrument of choice in drug or psychotherapy treatment research. The GCS is a 25 item scale that measures the client’s degree, severity, or magnitude of depression. It focuses largely on affective aspects of clinical depression. The assessment focuses on the respondents feelings with respect to behaviors, attitudes, and events associated with depression. Empirical research has showcased its excellent scores in both reliability and validity. The M-PTSD scale is a 35 item assessment designed for deployed veterans. This scale compliments the GCS as it focuses on both guilt and suicidal tendencies.
It is the appropriate instrument to administer to all of our combative veterans. It has performed extremely well in research and clinical settings (Friedman 2000). The PTSD Checklist is a 17-item self-report measure of PTSD symptoms based on DSM-IV criteria, with a 5-point Likert scale response format (Weathers FW, Litz BT, Herman DS). It is highly correlated with the Clinician Administered PTSD Scale (r=. 929), has good diagnostic efficiency (;. 70), and has robust psychometric properties with a variety of trauma populations. Through our research we have found nothing but overwhelming positive feedback for our assessment tools of choice.
Any specific disadvantages have not been noted in the scientific community. Existing data strongly supports each respective assessment tool for continued use in both clinical and research settings. Mr. Van Winkle would be given the GCS to fill out at on his second appointment. The clinician would then review the questionnaire and incorporate valid information into a CAPS interview. A diagnosis is then assigned based on DSM-IV criteria. As an additional clinical practice both the M-PTSD and military PTSD Checklist would be given as he would have screened initially positive for ASD.
Treatment plans at the OTC include the client’s diagnosis, specific treatment goals, and specific interventions to address these goals. The treatment plans are signed by the assigned case manager, psychiatrist, and consumer and are intended to be a document that guides the course of treatment.
At one point in his account, Mr. Van Winkle says, “”But there is no controlling the movie in my mind, and it tells me what I am going to face: sometimes brief glimpses into forgotten events; sometimes new, invented memories” (Van Winkle, Clint 2009, p. 83).
This quote reminded me of a promising intervention treatment known as Neuro Linguistic Programing (NLP). This will be the treatment Mr. Van Winkle will engage in. According to Foa, the treatment of PTSD, or other fear-based pathologies are dependent upon modification of the structure of the traumatic memory to include information (experiences) that transform the meaning of the memory structure. In transforming the memory structure at the root of PTSD symptoms, new information that is incompatible with some or all of its pathological structure must be incorporated into the memory schema itself.
Some of these erroneous patterns include the expectation that fear-related anxiety will persist unless it is escaped or avoided, conflation of unrelated anxiety with the specific trauma-induced anxiety, feelings of personal incompetence as a result of experiencing the anxiety or losing control, and thinking that the anxiety itself is dangerous (Foa, Keane, & Friedman, 2000; Foa and Kozak, 1986; Foa & Meadows, 1997). Recent research into the molecular basis of memory has revealed the phenomenon of memory reconsolidation.
A growing body of work is revealing that upon evocation at least certain types of long term or permanent memories are rendered labile and become subject to change and manipulation. This phenomenon is apparently distinct from extinction phenomena which are believed to lay down new memory traces but leave the original memory unaffected. By adding corrective experiences to traumatic memories, we are apparently actively modifying the memory itself (Bouton, 2004; Bouton & Moody, 2004; Doye‘re, Debiec, Monfils, Schafe & LeDoux, 2007; Nader, Schafe & Ledoux, 2000; Tronson & Taylor, 2007).
Here, the participation of the client in consciously accessing the problem state begins the restructuring of the problem state using the Ericksonian technique of prescribing the symptom. By actively participating in eliciting the problem state, the client gains an experience of control over what was understood to be an uncontrollable and unpredictable traumatic response. This is also represents an instance of the therapeutic use of Bandura‘s concept of self-efficacy in the context of PTSD treatment (Bandura, 1997; Erickson & Rossi, 1980; Haley, 1973; Watzlawick, 1974; Watzlawick, Weakland & Fisch, 1974; Watzlawick, Beavin & Jackson, 1967).
Because the State just accessed is, by its nature traumatic, it is important to interrupt the state‘s development as soon as possible after its identification. Andreas recommends moving into the client‘s field of vision and changing the topic by discussing the weather, favorite foods or any other innocuous topic. Such state interruptions are a mainstay of NLP and can be found throughout the literature. (Andreas & Andreas, 1987; Andreas & Andreas, 1987; Bandler, 1985; Bandler & Grinder, 1979; Bodenhammer & Hall, 1998; Hallbom, 2007, Unpublished; Watzlawick, 1974; Watzlawick, Weakland & Fisch, 1974).
Recent research that takes advantage of the Yerkes Dobson Law relative to the effect of stress on the consolidation and reconsolidation of traumatic memory reinforces the NLP position that while it is necessary to evoke the state, the level of reexperiencing trauma must be minimized in order to take advantage of the optimal states for reconsolidation of the trauma memory so that it includes the new information provided by the intervention (Diamond, Campbell, Park, et al. , 2007).
For all of these reasons, I believe treating Mr. Van Winkle with NLP would not only be effective but further the aid in the development of this innovative treatment. Treatment for Mr. Van Winkle would begin with imaginal context of a movie theatre where he watches and or participates in several versions of a traumatic combat memory from Iraq. Traditionally a client imagines that he or she is seated in a movie theatre. The imagined movie screen will show a still image of them performing some neutral activity in a safe context.
As they watch, have them dissociate from the image of themselves sitting in the theatre in one of the following ways: Imagining a physical dissociation by floating away to a projection booth behind a Plexiglas barrier, floating away from the body and imagining that they are standing behind the body holding their own shoulders and monitoring their own embodied state or by distorting the image sufficiently that no association to the image is possible.
Andreas suggests the following language.
Would that be all right with you?? Then reach out and hold a tuft of hair right where the curve of the back of the head meets the neck, and gently pull the client‘s head straight back, making sure that the client does not roll the head up or down, (or side to side) as you do this. (Andreas, 2007, unpublished). Dissociation ensures that the client will not be resubjected to the emotional impact of the original trauma.
Nevertheless, contact with an imagined self-watching the screen, and/or having the capacity to monitor postural and breathing changes that the client might exhibit if watching the imagined movie, are enough to ground the experience in the unique physiology of the problem state. In light of reports by Foa and Kozak (1986) that observing emotional responses and attending to representations of such responses can be crucial elements in eliciting emotional memories, the instruction to observe the watcher in the theater may be a crucial element in this phase of the procedure.
As in the elicitation phase, the practitioner will observe the client for signs of dissociation. These may include stillness, lack of facial expression and animation as well as changes in breathing and posture. As the client moves into the dissociated state, the practitioner should ask for permission and anchor the state (Andreas & Andreas, 1980; Bandler, 1975). When the practitioner is sure that the client is moving into the dissociated state he should then ask for permission to anchor the state. Anchoring is a general term in NLP that can mean almost anything from a structured lassical conditioning procedure using multiple iterations to produce the association between stimulus and response to a simpler mnemonic that may represent a species of one-shot learning with the client‘s approval. Rescorla (1988) seems to indicate that this is a reasonable understanding of the range of classical conditioning phenomena. In this context, the anchor is established by a gentle touch on the client‘s arm timed to correspond with their manifestation of signs of dissociation which may include relaxed posture, breathing, facial expression, tone of voice, etc.
Andreas (2007, unpublished) describes the procedure as follows: When you observe this, ask the following: ? Now I would like to gently place my hand on your forearm, and keep it there, to stabilize this state and to remind you of where you are. Would that be all right with you? Then place your hand, or a few fingers gently on the client‘s forearm and hold it there. Classical NLP texts indicate that in order to create an effective anchor the practitioner must take some care to make the conditioned stimulus distinctive and repeatable.
It is best, when using a touch stimulus as suggested by Andreas, to locate it in a place where it can be easily accessed and repeated in a reliable manner. Practitioners may often use blemishes, wrinkles, distinctive indentations or other marks to ensure that their anchors can be replicated as to place. There should also be an effort made to use the same level of force or pressure to create and evoke the anchor. While other sensory modalities may be used to create anchors, touch anchors—kinesthetic anchors—seem to be the preferred mode in this kind of work (Bandler & Grinder, 1979, Dilts & Delozier, 2000).
Once the dissociated anchor is established, the main portion of the procedure begins. This consists of two visual exposures played out in the client‘s imagination. The first is an imagined, dissociated, black and white movie beginning at a time before the trauma began and ending at a safe time after the trauma ended. The second is an associated color movie, played backwards and ending, likewise, in an associated, safe place.
Both fantasies may be understood as restructuring the meaning of the traumatic event and as increasing the client‘s sense of self-efficacy regarding the experience (Bandura, 1997; Tronson & Taylor, 2007). If we are unsure, we can ask Mr. Van Winkle how he experienced the exercise. If there is any indication of distress, especially mild distress, we will have him repeat the procedure several times until he can go through it without distress (Andreas & Andreas, 1980; Bandler, 1985; Dilts & Delozier, 2000).
If Mr.Van Winkle has continuing but not acute difficulty with the procedure, the procedure may be modified by instructing him to watch only the top half of the movie, followed by only the bottom half or to watch only every third second of the movie—all the way through, followed by every second of the movie—all the way through, followed by every first second of the movie (Dilts & Delosier, 2000; Andreas, 2007, unpublished). If Clint displays signs of acute distress, we should interrupt him, distract him and reorient him to the safe present.
As noted, this may be done by reorienting him to the weather, some pleasant diversion or what he was doing immediately before entering the therapeutic situation. Because of the possibility of strong reactions it may be useful to begin the procedure, after establishing rapport and setting the frame by creating a neutral, safe or dissociated anchor. This has been suggested by Dilts & Delozier (2000), as well as Hallbom (2007, unpublished).
If the client cannot run the imaginal exposure movie through without significant distress, the practitioner should go back to the third step and recreate the anchor for the dissociated state. Once an effective anchor has been established the first part of the procedure, dissociation and watching the movie may proceed. When the client has successfully watched the black and white dissociated movie without distress, remove your hand from their arm and then move on to the next step. Richard Bandler has repeatedly suggested that techniques used to affect a remembered experience work better when performed more quickly.
There is now evidence from neurophysiology that suggests that all of these re-experiences should be made to run as quickly as possible to take advantage of increased possibilities for the transformation of the now labile traumatic memory (Diamond, et al. , 2007). The next step involves a further level of memory restructuring. Beginning with the safe representation of the Mr. Van Winkle at the end of the dissociated black and white movie, he will be asked to imagine stepping into the movie and to experience the entire sequence, fully associated, in color, in reverse, at very high speed (two seconds or less).
This has several effects. Once again, Mr. Van Winkle is manipulating an event which has until now been experienced as beyond his control. He now takes control by accessing the event and by modifying it in terms of its direction, sequence and perceptual qualities. By running it backwards he dissociates from the trauma and recodes the memory as lessening through time and ultimately disappearing. By running the movie quickly, he furthers the dissociation from the event by overwhelming the capacities of short-term memory, and completing the whole sequence before negative emotional processes have a chance to build up.
Before negative emotions even begin to develop, Mr. Van Winkle has entered a clear memory of a safe place before the event occurred and his most current experience of the event is backwards. It has been suggested that the practitioner use the following language when describing the backwards movie: All the people will walk backwards and everything else will happen in reverse, just like rewinding a movie, except you will be inside the movie. Run it backwards in color and take only about one or two seconds to do it (p. 44).
Although Andreas suggests only one iteration of this step both Dilts & Delozier (2000) and Hallbom (2007, unpublished) recommend several iterations of stepping into the safe black and white picture and running the associated, reversed, color movie after testing for its effectiveness. Once Mr. Van Winkle has completed the procedure and has returned to a present neutral state, we must determine whether the procedure has had the desired effect. Again, in harmony with the observations of Foa and his colleagues (Foa, Keane, & Friedman, 2000; Foa and Kozak, 1986; Foa & Meadows, 1997), simple probes are insufficient.
The determination of success must be made based on physiological indicia. Once again we should make every effort to evoke the problem state. Ideally this is done using the same questions and probes used to access the problem state with special attention to those questions that were associated with a clear physiological reaction. If there is no reaction, the intervention is presumed to have worked. When we are satisfied that we can’t evoke the PTSD response, we can continue on to the next phase. Phase two involves the creation of alternative versions of the original event.
Andreas recommends its use only if there was actual physical trauma involved in the original traumatizing event. Although Hallbom recommends its use more generally, as do Dilts & Delozier (2000), the content of the intervention implies the existence of physical injury. Nevertheless, as the exercise represents the possibility of layering the now labile trauma experience with other versions of the event, this phase may be useful in all cases (Tronson & Taylor, 2007). As a debrief process we will ask Clint how he experienced the procedure. We will observe the non-verbal behavior of Mr.
Van Winkle. At this point he should display a resourceful and untroubled physiology. It should be free of the indicia of trauma elicited at the evocation stage and should be more congruent and balanced than at the end of the Phase One treatment. Hallbom suggests we have Clint describe the original traumatic situation while we calibrate for successful dissociation from the negative affect. If any evidence of negative affect remains, the steps of phase 2 are to be repeated.
The treatment efficacy plan for Mr. Van Winkle is simple.
Clint will be given the Posttraumatic Diagnostic Scale (Foa, Cashman, Jaycox, & Perry, 1997) and the Beck Depression Inventory (Beck, Steer, & Brown, 1996) at pretreatment, every other session during treatment, post treatment, and at our 6-month follow-up. The every other session trend is to ovoid exhaustion and yield accurate results. As previously discussed, in transforming the memory structure at the root of PTSD symptoms, new information that is incompatible with some or all of its pathological structure will now be incorporated into the memory schema itself (Foa, Keane, & Friedman, 2000; Foa and Kozak, 1986; Foa & Meadows, 1997).
This is the resulting factor of NLP. If all goes to plan, Mr. Van Winkle results should show significant steady reductions in feelings of anxiety, depression, and sleep deprivation, while simultaneously showing firm increases in self-confidence, trust, and overall demeanor.
After reading less than a chapter of the book, I discussed its contents with a friend who serves in the Army. I wanted to know if it some of its details were overblown. I discovered that his account was very similar to my friends experience in Iraq.
Van Winkle gives an honest look at what it’s like to be a combat Marine during wartime and upon returning home. Anyone with an opinion about the war should read this book and see if it alters their perspective. Anyone who has ever casually dismissed a veteran should do the same. I must admit, sometimes the narrative was a little difficult to follow or felt incomplete. Van Winkle seems to think he may have killed a little girl, and her image haunts him, but we never learn exactly how this happened.
He once turned the massive firepower of his armored assault vehicle on a stone wall, demolishing it and possibly massacring a group of men hiding behind it; but again we get no real context. There were also sections where it was difficult to separate what was real and what was flashback, but at the same time, that is also what made the book amazing. If you have studied or experienced Post-traumatic Stress Disorder, you understand the back-and-forth flashes. This is what makes you feel like you’re going crazy and is a primary symptom of the mental disorder. My war,” writes Van Winkle, “was an impersonal war full of indiscriminate firing and long-distance death. ” This quote really sets the tone for the reader and allows an insider’s vantage point on a US soldier’s postwar mindset” (Van Winkle, Clint 2009, p. 102). I think most readers will walk away from this book with a hopeful perspective. Van Winkle goes to war angry and blood-thirsty, looking to kill but that isn’t the Van Winkle that returns home. He explains the change when talking with his grandfather. “When I got back from Iraq, and saw my Grandpa, we talked about war again.
However, we talked about it in a different manner than we had years earlier. We talked about the places we saw, and the friends we gained. We bypassed the death and shooting. Our wars were sixty years apart but weren’t really any different. It didn’t matter how many years separated our wars or where we traveled to fight them. Blood still dried the same way around wounds, and charred bodies still crusted over the same as they always have. It didn’t matter that he’d fought in a “good war” and I’d fought in a controversial war; because the effect turned out to be the same: Neither of us could find anything praiseworthy about combat. (Van Winkle, Clint 2009, p. 107). Overall, this is a good book, one of the better war memoirs I’ve read so far. It is honest, has a good message, and overall there is more to like than dislike in Soft Spots.
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