Crisis Continuum

The Crisis Continuum is a detailed plan to help identify impulses on a continuum of severity.  Then, for each level of severity, you identify actions necessary to stay safe.

Ok, that’s a lot of words, so let me give you an example.

Imagine a time you went from 0 to 100.  You escalated seemingly from a state of calm to a state of crisis.  Think about the crisis and what you (or parts) were thinking, feeling, and experiencing in the body at the time.

To give you an idea, here is an example.  I bolt upright in bed, awakened due to a nightmare.  I’m alone in the dark.  I’m feeling helpless because this is the 7th night in a row of nightmares.  It seems like my work in therapy is just making nightmares worse.  I’m trembling, my heart is beating fast, and I hear something fall off a shelf in the closet, really kicking my panic over the edge.

Here’s what my Crisis Continuum might look like for this scenario:Screen Shot 2018-12-27 at 9.38.01 PM

A complete Crisis Continuum will have “levels” of severity from 1 through 5.  1 = state of calm up to 5 = state of crisis.  Generally, it’s easier for PTSD/DID folks to by filling out the continuum with level 5, since that’s the level we’re most familiar with.  Then, go all the way back to 1 and fill out for the polar opposite, a state of calm.

Once you have the 2 extremes done, you can go back in and fill in the other levels.  An empty Crisis Continuum might look like this…

Screen Shot 2018-12-27 at 9.55.37 PM

It’s okay if you don’t know a whole lot of actions you can take to stay safe.  This is probably the hardest tool to complete in the beginning of doing this work, but it’s the most important one to have in place.  You will likely find yourself re-doing CC’s as you increase awareness about your system and learn new symptom management skills.

Be safe

-Nel

 

Advertisements

Phase One and Symptom Management

As I’ve been doing more work with our therapist, K., I’ve been reviewing some of the tools I learned at Sheppard Pratt this go around.  Some visitors who have never heard of the skills I’ve brought home have been asking for a better understanding of what I’m referring to.  Before I start sharing these skills and how I use them, I thought I’d talk a little bit about why I use them.

Sheppard Pratt follows the Triphasic Model of Trauma Treatment.  The three phases are:

  1. Safety and Stabilization – Establishing safety, Recognizing symptoms, Creating emotional stability
  2. Processing Trauma Memories – Done in outpatient therapy, using Phase One skills to not be stuck in avoidance or overwhelmed with traumatic material.
  3. Integration – Referring to an integrated understanding of the current day, present, healed self. Trauma is part of your life story, but not the main focus anymore. This does not refer to integration of alters or parts.

[Source, Adapted from Herman, 1992]

Since Sheppard Pratt is an inpatient hospital, their main goal is to return the patient to their outpatient team with Phase One goals of safety and stabilization accomplished.

Before learning skills, safety is paramount.  In our case, we had to work with parts and our inpatient team to identify who was unsafe, their thoughts about safety, and their reasons for a lack of motivation to remain safe.  As is always the case, we discover underneath the chaos of safety issues, an immense emotional pain.  Helpling parts understand this isn’t “bad” behavior, they aren’t in “trouble”, and most importantly they aren’t alone–that we don’t have to hurt the body anymore in order to be heard–is vital.

Once risky behaviors have been identified, and there is some kind of mutual safety agreement, and safety plan in place, we can begin working on symptom management.

Many of the symptom management skills are specifically learned in Phase One of trauma treatment.

Side Note: I feel it is important to be clear, here.  I have twelve years of trauma treatment under my belt.  Even after all this time, I learned helpful tools going back to Phase One.  There has been a wealth of research on DID over the past twelve years.  I had no idea I was missing out on skills.  Many of the skills gave me a sense of power and control back over my life.

Symptom Management skills are basically lumped together under the following categories:

  1. Crisis Planning
  2. Grounding techniques
  3. Breathing/Meditation/Imagery
  4. Medications (PRNs)
  5. Addressing Co-occurring Disorders
  6. Hospitalization if needed to prevent harm to self or others

Besides establishing safety, the overall goals of symptom management include (1) enhancing awareness, (2) emotion regulation, (3) decreasing affect (or part) phobia, (4) building distress tolerance, and (5) enhancing effectiveness in personal relationships (and with parts). [Source]

In the upcoming posts, I plan to talk a little bit more about what each category is, and the things I learned to support our DID System find things that worked.

Endogenic Systems, Tulpas, and their place in DID Communities

Endogenic Systems is a non-clinical term which seems to have originated on Tumblr.  It refers to people without trauma-based dissociation who claim to have alternate personalities that were consciously created.  These individuals acknowledge their personalities were willfully created, and describe them as having their own likes, dislikes, personality, and lives.  The key difference is there there is no amnesia between parts, since there is no clinical dissociation happening.

Tulpas are also included when discussing Endogenic Systems, but they are somewhat different.  The creation of a Tulpa is a spiritual experience, and the relationship the person has with his/her Tulpa can be quite impactful.

As you can imagine, this concept ruffles the feathers of many with trauma-based dissociation.  Many of us have faced a lifetime of invalidation of our abuse, and similarly our diagnosis.  The mental health community is woefully undereducated on trauma disorders, and sometimes our initial experiences with therapists does even more harm.  Our diagnosis is further vilified in media and fiction movies like Identity (2003) and Split (2016). This makes it difficult for us to fully trust in our interpersonal relationships, because other people’s only awareness of the diagnosis are from these extreme fiction examples.

And then, there’s those of us with DID and Ritual Abuse.  It’s not uncommon for us to have parts that aren’t fully formed identities.  We may have a part “in control” of creating fake or temporary parts for a programming purpose.  These temporary parts are sometimes referred to as spirits, demons, shadows, etc.

Our system refers to them as shadows.  Shadows exist to fulfill an order, and when that is completed, they collapse back into the elements they were created from.  The part who controls their development and demise, then collects these elements and stores them away the next time they are needed to create.

I often witness discussions in online DID communities, and I see the vitriol and hatred towards Endogenics and Tulpas.  I understand where this is coming from, but at the same time, my heart hurts because I know I surely would be attacked for siding with the less-than-popular opinion that parts can consciously be created, destroyed, etc. at will in some systems.   Attacks by the survivors we would be able to relate to.

This can trigger other programming as well.  Programming designed to make us believe that we will never be believed if we try to tell about the ritual abuse.  And when we witness such hurtful responses from the DID community, it only reinforces our abusers’ messages.

It can get destabilized and confusing in our head very quickly with multiple programs being fired off like this.  I only wish the DID community could be more open-minded and accepting, instead of impulsively reacting and unknowingly hurting others.

 

Daily Symptom Management Goals

One thing being inpatient tends to do very well is kick my depressed butt back into a routine.  I took a lot of what worked from inpatient, and this time I implemented it when I got home.  It gave me a sense of safety/comfort going through some familiar motions.

The most important piece of this routine was setting daily goals.

Goals were set around symptom management skills we were learning or implementing.  Sometimes it was in reference to assignments we were working on with our individual therapist or psychiatrist.

We outlined 2-3 goals (no more than that) for each day.  Some were the same day after day, if it was a concept we were struggling learning.

Here are some of the goals I practiced while inpatient earlier this year:

  1. Work on my Crisis Continuum.
  2. Increase motivation for safety.
  3. Internal Communication to identify safe places.
  4. Work on a System Map.
  5. Hold at least 1 Internal Meeting.
  6. Share (at least the 1st section of) my System Map with therapist.
  7. Make a list of my accomplishments from working in therapy.
  8. Rework internal space to include an anger room.
  9. Cognitive Distortions assignment regarding the thought “I’m overreacting”.
  10. Boxes of Control regarding grief/loss.
  11. Cluster Journal one time today.
  12. Do Grounding Checks every 30 minutes.
  13. Make a list of Grounding Techniques based on age-appropriateness for different parts.
  14. Make a list of Self-Soothing strategies.
  15. Make a Containment strategy.
  16. Do Feelings Checks every 30 minutes.
  17. Do a Past vs. Present on loud noises as a trigger.
  18. Read Chapter 5 of the Coping book.
  19. Create an Orienting Card.
  20. Create a list of early warning signs that a flashback or increase in dissociative symptoms may be coming.
  21. Practice Dialing Down.
  22. Create a BDA for the shower.
  23. Create a Bedroom routine (for going to sleep).
  24. Create a Nighttime routine (if I wake up in the middle of the night).
  25. Maintain safety by using Opposite Action if I want to isolate.

Worry and Fear: My constant companions

This morning, I was reading a daily affirmation about excessive worrying.  In a nutshell, the affirmation said excessive worrying is a common trait of survivors.  That it’s okay to feel worry–but that we can work towards being grounded and present in the moment and feel positive about ourselves.

Meg, one of my teen parts, snorted, slammed the book shut, and shoved it to the side of our kitchen table. What a bunch of crap. She folded her arms across her chest. Like it’s that easy.

I could see where she was coming from.  In working with many of my child parts, it’s super hard to decrease their anxiety.  Some of my parts are so firmly locked in “trauma time” that they’re in a perpetual state of terror. Even those parts that are grounded in the present balk at K., our therapist, and her attempt to ground us: “It’s 2018. You’re safe.” What happened to us is real. It happened many times. It could happen again!

To be clear, we aren’t in any danger of being abused. It’s just so hard for my parts and I sometimes–even when we know we’re okay–to truly feel safe.

Within the ritually abused parts, there are some who still throw out programming and flood us with terror on purpose (for talking in therapy). I haven’t the slightest idea how to even begin with those parts.

I have this baseline of anxiety all the time, and I guess we have a lot to be anxious about. Besides going about being a “normal” adult with a full time job, a fiance, a family, friends…I’ve got a second full time job and family inside that constantly needs redirecting that we are safe. We are nowhere near perpetrators. Then the backlash comes when parts who want to be near perpetrators trigger off programming.

In my last session, I was crying to K. (which I rarely do–actually cry in front of her). “I haven’t been in my body in months.” I sobbed. “I hate this feeling. I hate only being half-present. The last time I felt in my body was at Sheppard Pratt.  What do I have to do? Go inpatient every time I want to feel grounded again? I can’t keep going inpatient.”

“What do you do?” K. paused. She waited until I looked up at her again. “Internal communication.”