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TSR Training for Veterans. David A Fohrman, M.D. What is TSR Training?. Traumatic Stress Resiliency (TSR) Training is a program to teach you how to avoid getting PTSD Essential to Have Easy to learn Takes about 30 minutes. What is the Problem?.

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tsr training for veterans

TSR Training for Veterans

David A Fohrman, M.D.

what is tsr training
What is TSR Training?
  • Traumatic Stress Resiliency (TSR) Training is a program to teach you how to avoid getting PTSD
    • Essential to Have
    • Easy to learn
      • Takes about 30 minutes
what is the problem
What is the Problem?
  • Veterans have a high risk for getting Post Traumatic Stress Disorder (PTSD)
    • Veterans also on active duty
      • In national guard or reserves
      • For example, approximately 30% of the OIF/OEF veterans have impaired due chronic PTSD symptoms
      • With each deployment, the number goes up
    • Veterans have a 90% of experiencing a non-military related traumatic event
      • These traumas can lead to PTSD
      • higher risk if already have PTSD, from combat or non-combat related experiences
      • had a traumatic brain injury (TBI)
what is the problem1
What is the Problem?
  • PTSD symptoms (such as flashbacks, nightmares, chronically feeling jumpy, irritable, angry, anxious or depressed) cause serious problems
    • at work, home, in life
      • Lose job, marriage, friends, interests, life (suicide)
  • PTSD can be very difficult to treat
    • especially chronic PTSD (having PTSD symptoms for more then six months)
what is the solution
What is the Solution?
  • Prevent PTSD before it develops
  • Diagnosis of PTSD
    • Wait at least 30 days after traumatic/stressful situation ends
      • In case of a deployment, time closer to 3-6 months
    • If symptoms resolve prior to this window, will not get PTSD
      • If you already have PTSD from prior deployments/non combat related traumatic situations, TSR training can still help
tsr training
TSR Training
  • Helps avoid road blocks that keep your body from naturally recovering from the effects of traumatic events.
  • Two parts
    • #1: What is PTSD
    • #2 What are the six road blocks to recovery and how can we avoid getting them
what is ptsd
What is PTSD?
  • PTSD is biological problem
    • A disorder due to our brain’s creating abnormal trauma induced memories.
    • These memories cause you to experience almost all of the symptoms of the symptoms of PTSD
    • Intrusive recollections of trauma
    • Avoidance and numbing symptoms
    • Hypervigalence and hyperarousal symptoms
what is ptsd1
What is PTSD?
  • PTSD is a spiritual problem
      • A disorder due to the creation of abnormal trauma induced faulty beliefs
    • Traumatic events can cause people to lose previously held core beliefs
      • Core beliefs are things you believe to be true but don’t think about
        • Examples are when I go through a green light other drivers will obey the traffic signal and stop
        • When I really need help, people I trust will help me out.
    • As a result of trauma, people can become lose their self confidence, not trust other people, become very cynical, think everything is ‘worthless or meaningless’ and/or may lose previously held religious beliefs
what is ptsd2
What is PTSD?
  • PTSD is a disorder due to a failure to naturally recover from the effects of trauma
    • All traumatized people temporality have some symptoms of PTSD
  • People get PTSD when they are unable to naturally recover
    • They don’t recover because trauma creates six road blocks to recovery
    • Soldiers have not been taught how to avoid these roadblocks.
six roadblocks to recovery
Six Roadblocks to Recovery

#1 – Can’t feel safe

#2 – Can’t relax

#3 – Emotionally isolate self

#4 – Unable to stay in optimal zone for recovery

#5 – Avoid talking about trauma

#6 – Unable to fix trauma created faulty beliefs

six steps to recovery
Six Steps to Recovery
  • Use mnemonic: GROWTH
    • G – Go to a Safe place
    • R – Relax
    • O – Open Up
    • W – Wait until you are ready
    • T - Tell your story
    • H - Heal
g rowth g o to a safe place
GROWTH: Go to a Safe Place
  • Feelings safe means feeling both physically and psychologically safe
    • Physically safe – feel will not be unexpectedly hurt or killed
    • Psychologically safe – feel will not be taken advantage of while experiencing strong negative emotions
g rowth g o to a safe place1
GROWTH: Go to a safe place
  • Examples,
    • At home
    • With friends
    • Doing an activity you enjoy
      • If you are doing something you enjoy, you feel safe
      • Can use handout to help you figure out what is a safe place for you
roadblock 1 don t feel safe
Roadblock #1: Don’t feel safe
  • Traumatic events can make us chronically feel unsafe
    • Like we might unexpectedly be in a life threatening situation
      • may sit with back against wall in restaurants
      • Avoid or really dislike crowds
    • For those that have never experienced this feeling
      • Like not having enough oxygen
        • Very hard to do anything other then try to feel safe
avoid roadblock 1 don t feel safe
Avoid Roadblock #1: Don’t feel safe
  • Regain sense of safety after trauma.
    • Practice gradual exposure technique
      • When something makes us feel afraid one of two things happen
        • We freak out, panic, feel horrified, helpless, etc.
        • We stay in control; with time, anxiety will go away
          • Each time we stay in control will feel less and less anxious



g r owth r elax
  • May think of one goal for relaxation:
    • ‘de-stress’
  • Two Goals:
    • 1. contain excessive emotion
    • 2. regain a sense of being in control
roadblock 2 can t relax
Roadblock #2: Can’t relax
  • Traumatic events can make it hard to relax
    • Chronically activate fight or flight response
      • Feel anxious nervous, increase heart rate, blood pressure, dilate pupils
      • Can’t relax while fighting or running away!
    • Trauma are events where things are “out of control”
      • Can chronically feel this way
avoid roadblock 2 can t relax
Avoid Roadblock #2: Can’t relax
  • Relax after trauma by having relaxation techniques that work for you
    • Can use breathing technique, described in handout
    • Use any other technique that works
      • Literally hundreds of books in library, book stores
    • Can use tapping technique to make flashbacks go away
  • Make sure you can feel in control “again” after trauma
    • Figure out what you enjoy doing
      • Hobby, sport, work, being a parent,
      • Do this in “easy way” after trauma to help you feel in control again.

Can use relaxation techniques to help with prolonged exposure

gr o wth o pen up
GROWTH: Open up
  • Collectively, we can emotionally deal with what we can not deal with alone
    • True both in military and civilian settings
      • Enemies that are emotionally resilient are very difficult to beat
        • Examples are soldiers during war of Independence
    • True psychologically and biologically!
roadblock 3 emotionally isolate self
Roadblock #3: Emotionally Isolate Self
  • Traumatic events are situations were people close to us can be hurt or killed.
    • When this happens there is a natural tendency to emotionally pull back
      • For a limited period of time
    • Like having a rubber band snap on ones fingers
      • More cautious next time
  • Problem: people choose to constantly isolate self
    • minimize emotional contacts
avoid roadblock 3 emotionally isolate self
Avoid Roadblock #3:Emotionally Isolate self
  • Use handout: Suggestions for Opening Up
    • First talk about Easy Topics
    • Then talk about more difficult topics
  • Talk about the what, where, when, how for each topic
gro w th w ait until you are ready
GROWTH: Wait until you are ready
  • Wait until you are ready
    • You need to be in your “optimal zone for recovery” before continuing
    • If you are below your optimal zone – your brain will not process memories
      • This happens when you drink alcohol, use drugs or actively avoid thinking about the trauma
    • If you are above your optimal zone, you will not re-process your abnormal trauma induced memorieswhich will make it harder to fix them in the future
avoid roadblock 4 can t fix abnormal trauma memories
Avoid Roadblock #4: Can’t fix abnormal trauma memories
  • When your ready to recover, make you’re you are in your “optimal zone for natural recovery”
    • Some people are ready to start recovering a day or two after the event, others wait weeks or a couple of months
  • Use the handout: Optimal Zone for Recovery” to make sure your brain is biologically in the right place before you talk about the trauma with someone else.
    • Doing this will increase the speed in which your brain will fix it’s abnormal trauma induced memories
grow t h t ell your story
GROWTH: Tell your story
    • The best way to recover from the effects of trauma is to talk about it
    • Name for this: Natural Debriefing
  • Teaches you how to naturally debrief
    • Something we do often do after a stressful day
      • We talk to a spouse/significant other or a loved one
      • Talking doesn’t change ‘what happened”
        • Still, we feel better
  • In case of trauma
      • Talking also helps brain re-process trauma created abnormal memories
      • Easier said then done
        • We don’t practice talking about trauma
      • Trauma usually a rare event
        • Something people keep to themselves
roadblock 5 avoid talking about trauma
Roadblock #5: Avoid Talking about trauma
    • Traumatic events bring up:
      • very strong emotions like horror, helplessness, intense fear, anger, shame, guilt
      • Thoughts, beliefs about ourselves, others or the world that are very distressing
        • “It was my fault”
        • “I can’t trust anyone because of what happened’
  • Natural not to want to talk about, let alone think about, these things
avoid roadblock 5 avoid talking about trauma
Avoid Roadblock #5: Avoid talking about trauma
    • Practice by:
      • First thinking of something that bothers you
        • if have a hard time, think of a time when you “over reacted’ to something – for example, became angry for little or no reason
        • think about something that irritates you; bothers you only a little
      • write down, in outline form, what happened
  • use handout: Tell your story for an example
      • tell this story to someone else
        • if feel overwhelming emotion, stop
        • main thing is the process
        • does not matter how long you speak as long as you stay emotionally in control
session 6 h eal
Session #6: Heal

Healing occurs when your past traumas no longer holds you back from living your live the fullest

  • Healing occurs in two ways: Biologically, Spiritually
    • Biologically
      • reprocess abnormal trauma induced memories
    • Spiritually
      • Fix any trauma induced faulty beliefs
heal biologically
Heal Biologically
  • Process abnormal trauma induced memories
    • Stop uncontrolled reactivation of event, flashbacks, etc.
  • Stop excessive fight or flight activation
    • Stop startle reaction, irritability, hypervigalence
heal biologically1
Heal Biologically
  • Fill out the PTSD symptom checklist, any symptom you have more then ‘rarely’ is a positive response
        • If you have any positive response, use the GROWTH technique to help make these symptoms go away.
        • If you still have symptoms for more then two months after using these techniques, get additional help!
          • PTSD can be very difficult to treat!
heal spiritually
Heal Spiritually
  • Trauma causes us to lose things important to us
    • Both concrete/specific and beliefs
  • This causes us to:
    • disconnect with ourselves
      • “live in your head” and become excessively stoic
    • disconnect with others
      • Emotionally as well as physically
    • disconnect with our beliefs/ideals
      • Start questions basic/or long held secular and/or religious beliefs
heal reconnect to yourself
Heal – reconnect to yourself
  • Identify if you are disconnected
    • Difficulty experiencing/expressing intense emotions
    • Experience unexplained medical problems
  • Heal by being able to experience emotions without getting overwhelmed
    • By body sensations
    • Thoughts
  • Recover from unexplained/stress induced medical problems
    • Especially gastrointestinal, headaches, other unexplained aches and pains
    • Sexual dysfunction
      • Need to be able to express intimacy and aggression
heal reconnect to others
Heal – reconnect to others
  • Identify if you are disconnected
    • Physically isolating oneself
    • Emotionally isolating oneself/avoiding emotional intimacy
      • Honestly/behavior will tell you if this is an issue
        • What would an ‘fly on the wall’ say you are doing
  • Often held back in emotionally reconnecting because of our trauma induced beliefs
heal reconnect to your beliefs
Before being traumatized

(1) I am in control of my life

(2) I am competent.

(3)I can reach my goals

(4) What I think, feel, say and do effects other people

(5)I can control how I spend my time

(6) I am usually pretty healthy person

After being traumatized

(1)My life is out of control

(2)I am basically incompetent.

(3) I can’t accomplish what I set out to do

(4)My actions, thoughts, and feelings do not affect any one but me

(5) I can not take control of how I spend my time

(6) I am usually sick

Heal -reconnect to your beliefs

Handout - Identify if you have trauma induced beliefs

heal re connect to your beliefs
Heal re-connect to your beliefs
  • Use questioning of beliefs as an opportunity to growth
    • Other cultures view trauma as a rite of passage
    • Opportunity to grow
  • Researchers have a name of this: Post Traumatic Growth
    • As a result of living through a potentially life threatening event, people often report they now
      • ‘try to live each day to the fullest’
      • ‘do things (like hobbies, going on vacations, etc.) that they had put off doing before’
      • ‘feel that their life is more meaningful’
      • ‘are closer to their friends and family’

Pragmatically – emphasize decision to prioritize “connecting”

change your actions change your life
Change your actions, change your life
  • Use OIA acronym.
        • Observe
        • Imagine
        • Act
  • Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to
    • examples: spouse tries to talk to you, you pretend not to hear him/her
    • first identify situation retrospectively, then Use OIA acronym.
        • Observe
        • Imagine
        • Act
  • Observe for situations where you are doing thing that result in you being more emotionally distant from people you are close to
    • examples: spouse tries to talk to you, you pretend not to hear him/her
    • first identify situation retrospectively, then
  • Imagine – how you would act if you wanted to emotionally connect
    • example – spouse talks to you, you listen
      • Use active listening skills
      • We all have them, but don’t always use them
    • Identify at what stage of moral development client is – speak to them at that level
    • Practice scenarios that could happen
  • Act as if you want to emotionally and physically connect
  • This may or may not be connected to your current beliefs
  • May be an ‘act of faith’
    • Faith means different things
    • This is secular
      • Refers to acting in a way you hope (or wish) were true even though you may not belief it’s true
  • Act first, and your beliefs will follow
final points
Final points
  • Trauma happens!
      • PTSD and other long term post trauma problems don’t have too
  • Can use GROWTH to help you and your loved ones recovery from the psychological effects of deployment.
  • G - Go to a safe place
    • R - Relax
    • O - Open up
    • W -Wait until you are ready
    • T - Tell your story
    • H - Heal