Category Archives: Safety

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

 

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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.

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.