Category Archives: Symptom Management

Containment, for the win!

I had therapy yesterday with our therapist, K.  We spent the session reviewing some therapy homework.  At the end of the session, I told her there was something I needed to say.

K. waited, quietly.  Sometimes she takes the approach of saying nothing, to allow my to get internal communication or put my words together.

I continued, “It’s to do with being in the shower.  Nearly every time I’m in the shower, I hear things people said to me.  I never have a picture memory, it’s just these things that were said.”

K. waited.  I didn’t say anything.  “Do you need to say them outloud?”

“I don’t want to say them outloud.  I don’t want to hear it, even though I hear it in my head all the time.” My eyesight diverted to the floor as the shame came on.

“Could you write them down?” K. asked.

I thought for a moment. “Yeah, maybe.  I mean, it might work.”  I reach over for my journal.

K. stopped me.  “Would you rather write them on a sticky?  Instead of having them in your notebook, where it might be difficult to tear it out, if someone doesn’t want the words in there?”

I feel a big YES! from inside.  I nod.

K. hands me a stack of blue sticky notes.

I’m including the following words I wrote for support.  However, there is no expectation you read them.  Often, I click on trigger warnings out of curiosity.  I want you to know that the words below are NOT safe. I do NOT expect you to read them.  In fact, they are not necessary to “get” the rest of this post.

Trigger Warning:  Graphic words behind this break!
      • “You like that, don’t you?”
      • “She likes that.”
      • “I’m going to make you —.
      • “You’re going to —, NOW.”

I handed the sticky to her.  “I want to leave these here.”  I don’t remember if she read them or not.  But as I told her I wanted to leave them, we simultaneously spoke internally.  Parts understood that the memory/words would be left behind in her office.  Everything tough that comes along with it would stay there, safe, until next week.

It was a success in Containment! I did some grounding skills and was able to leave/drive safely home.  Today, I have had zero “fallout” from the session, which is a-freakin-mazing.

It’s great to be reminded that I can use these symptom management skills, and–oh yeah–they DO work!


BDA Plans

I’ve had several requests for more information on Before During After (BDA) Plans.  This is a symptom management techniques I learned at Sheppard Pratt last year.

BDA Plans are used to prepare for events that may cause an increase in CPTSD and/or DID symptoms.  You might use them to plan for both positive and negative events.  This includes things like holidays, appointments, or telephone calls.

The plan has three sections, aptly named Before, During and After (the event). In each section, you identify what symptom management skills you can use at each point.

Some things to note:

  • Before starts whenever you need it to start.  This could be anywhere from days to hours before the event.
  • During is helpful to focus on grounding skills or whatever else you need to do to stay present.
  • After is just as important as any part of this plan, to help you in case of any impact after the event is over.  Self-soothing and Internal Communication (if needed) are very important here.
  • Use your Crisis Continuum as a guide to incorporate things that help into the BDA.

To give you an idea of how a BDA looks when all pulled together, here is one that I developed at Sheppard Pratt:

Event: Taking a Shower

Screen Shot 2019-02-12 at 1.01.33 PM

Screen Shot 2019-02-12 at 1.01.55 PM

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As you can see, Internal Communication is a big part of the entire process.  What helps us is the BDAs not only helps us plan for difficult situations, but helps us have a script/talking points for Internal Communication.  This plan in particular has been very helpful in building trust between parts during a vulnerable moment and in turn giving us power in our recovery.

Grounding Techniques

Why are Grounding Techniques so important?  I used to put little importance into learning them, because I felt like it was a waste of time, when I needed to work on uncovering trauma and processing memories.  Wellllll…doing trauma work kicks up trauma disorder symptoms, and if you can’t keep those symptoms “in check” … you can’t do the work.

Grounding Techniques are great because they assist with CPTSD symptoms (e.g. flashbacks, hypervigilance, panic, intrusive thoughts/feelings), and dissociation symptoms (e.g. trances, timeloss, uncontrolled switching).

Grounding helps us be present in the moment, connected to the here and now.  Ugh, why would I want to do that, when I’m in so much emotional pain all the time?  Well, that’s exactly what happens when you are not grounding.  By allowing symptoms like avoidance and dissociation to be our main coping strategies, it only reinforces feelings from the past (like the emotional pain).  In fact, surviving day-by-day casts a shadow of doubt on our future.  When even the future looks so bleak, no wonder we can’t fathom connecting to the here and now!

Increasing our present-awareness actually gives us a defense against the symptoms and control back over our lives.  There are loads of techniques out there that help people.  The trick is finding the ones that work for you (and which ones work/don’t work for each part).  Here are some grounding strategies people find helpful:

  1. Anchors – These are items in/around your home (or other place you spend a lot of time–school, work, etc).  Find things that are neutral or pleasing to you.   Hear them, touch them, connect to these things in the present.  If this is your first time finding anchors, slowly walk around your house, from room to room, and find at last 3 items that you can choose as anchors.  It’s especially helpful if these are items that were not around during your trauma.  Eventually, you will be able to identify anchors in each room, so that no matter where you are, you have something that can ground you to the present.  Here is a personal example of anchors for me:

I walk into my living room after a long day of work.  I take off my winter coat and hang it up on a hook.  I take off my purse and hang that up as well.  It was a very stressful day at work, and something that happened on the job kicked up overwhelming stress and shame.  I feel so stupid, I hate what I said, and I wish I could just erase the whole day.  Instantly, one of my child parts is crying, and another part wants to engage in self-harm due to the shame.  I feel the body’s heart rate pick up, and I realize a 3rd part is headed into an anxiety attack.

“Hey guys, I know it was a stressful day, but it’s over now.  The only thing we need to do now is relax.” I take my parts away from the door and show them our living room.  “I know some of you feel like you’re stuck in trauma time, but that time is over, see?”

I point to our large flat-screen TV. “It’s 2019. We didn’t have a TV like that when we [at unsafe place], right?”

Then, I sit down on the living room couch and point to a big blown-up photograph on the wall  which is of the body eating breakfast outside in Austria.  “Oh, look! That’s Salzburg!  We went to see where Sound of Music was made.  Remember what Austria was like?”

If parts who are struggling didn’t go to Austria, we might share the experience with them in detail.  Or, we might try a different anchor: “Do you like this bracelet? It’s a grounding bead bracelet we made at Sheppard Pratt.  Do you want to help me make a new one?  Which color should we use?”

Some of the things, like the grounding beads, and other art supplies, have a special place in our living room, so we know that’s a good “grounding/anchor spot” we can always count on being there.

2.  Grounding Bag or Grounding Kit – We keep a clear makeup bag like this in our purse.  This makes them visible and easy to access in a moment of need.  Inside, we have a conglomerate of items that different parts find soothing, like:

  • Burt’s Bees Lip Balm (the tingling sensation is sooo grounding)
  • Peppermints
  • Gum
  • Tea Bags
  • A few colored pens (pink, purple) if parts want to write in our journal
  • Lavender scented hand lotion
  • Essential oil (with roller) I can roll on my skin if I need to smell something calming (we link cinnamon)
  • Fidget spinner
  • Silly putty
  • Grounding stone (a smooth river rock)

3.  Soooo many more ideas… There are just way too many for me to go on about.  Beauty After Bruises blog has an excellent post about Grounding and gives a nice list of ideas for you to try out.

My last bit of advice…is keep a list! It can be overwhelming to be introduced to so many new things.  As you try skills that work for you, keep a list in your journal to easily flip to when you need a refresher.

Here’s to a happy, in-the-moment, New Year!

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