Finding Connection: Therapist Attunement and Self-Regulation When Clients Shut Down or Dissociate

welcome to the developmental trauma disorder clinical training series sponsored by the University of Connecticut center for treatment of developmental trauma disorders my name is Michelle Levinsky and I will be facilitating today's training before we begin I'd like to share a few reminders if you experience any technical difficulties at any point you may e-mail us at help at NC t SN org the format of this training does not allow you to speak directly to the panelists however we encourage you to use the Q&A feature on WebEx we'll try to answer questions that are submitted during our question and answer section of the training we encourage you to review the case background information prior to this training this document can be downloaded anytime from the NC TSM Learning Center today's training will be archived on the Learning Center website this makes it possible for you to view the presentation at a later time as well as complete a short evaluation the C e post-test and print a c e certificate at any time for anyone wishing to receive c e credit for this training no hardcopy certificates will be mailed the National Center is approved by the American Psychological Association National Association of Social Workers and the California Board of Behavioral Sciences to offer seee credits today's webinar finding connection therapists attunement and self-regulation when clients shut down or dissociate will be moderated by dr. Julian Ford P I of the ncts n category to cite University of Connecticut Center for treatment of developmental trauma disorders dr. Ford would you like to begin thanks very much Michelle and welcome everyone we've got a great webinar again today we're going to be revisiting three of the therapy dramatizations that many of you have already Sene but we're going to be taking a look back at moments in those dramatizations in those films that are particularly challenging for the therapist when they are working with clients who are very shut down or become very shut down or dissociate and those are times when the therapist own internal self-regulation is so crucial because we all react when we don't feel that sense of connection so we have a wonderful opportunity now to revisit three dramatizations and our learning objectives as you can see are we want to we want all of you to be able to describe expectable reactions that therapists have when clients do shut down or dissociate and one way in which developmental trauma might lead that actually happen and also to be able to identify one way in which we as therapists can help our clients who are shut down at associating to actually recognize and draw on their personal resilience in order for them to be able to self-regulate and finally we hope that by by the end of this webinar you'll be able to identify at least one strategy and maybe many for therapist self-regulation when this occurs so we have a wonderful set of dramatizations and a wonderful panel and that includes I'll go in the order in which they will be presenting and presented dr. Margaret blaustein dr. bill Saltzman and dr. Rocio Chang and I'm very happy to be your moderator so our first film well first let me back up this is part of a webinar series that we hope many of you have had a chance to see and now what we're really focusing in on is those moments where it's not necessarily an obvious crisis but where the connection between the therapist and the client has been frayed or maybe entirely lost and at those times all of us who are in the role of counselor or therapist or help her in any way it's it's just natural that we're going to experience a sense of disconnection and our own internal reactions and sometimes that's called counter transference because these are often reactions that our clients are having because we're touching on in the therapy some incredibly personal and often painful and difficult issues and memories that then require a kind of an adjustment that sometimes takes the form of just shutting down and becoming numb doubt or dissociating so the challenge for us as therapists and counselors and a challenge that we want our clients and family members to understand that we're working on because we have to work on this ourselves as well as asking them and helping them to work on a very similar challenge the challenge is how to self-regulate and regain or maintain or even enhance the kind of attunement that we have with the person or the persons who were working with and that's what you're going to see three therapists challenge to bridge that disconnection that comes from dissociation and emotional shutting down and every therapist has their own unique way of handling the challenge but there are three common denominators that I think you'll see in these film dramatization first is be able to recognize our own reactions as helpers and not judge those recognize that those are human reactions and reactions that we have is caring helpers and second to be able to communicate to our clients to everyone who's involved in the session that it's essential that we're all safe and that this is a session in which everyone is treated with respect and finally the third challenge and common denominator is really to be able to focus on and understand how the shutting down or the dissociation is actually part of an adaptive reaction it's part of the resilience of our clients and protecting themselves and how to bridge that into other ways of being resilience that enable them to come back into connection that's really the challenge so we'll see three brief films each of these shows moments critical moments of disconnection I want to remind you that the clients and the films are actors they are not the actual individuals but they are acting in a way that is very lifelike and the situations they portray and the therapists we're working with them are very real and we as therapists who have done these sessions we know these are as real as any sessions that we've ever done after each film will hear from the therapist to guineans an inside look at her or his reactions and then we'll talk as an expert panel and we'll take your questions and love to hear your reflections as well and during each discussion we really want you to send in your thoughts your observations your questions please do that using the chat box at the lower right hand corner of the webinar screen and we'll address as many of those as we can so now let's move right into the first film and here you're going to see a young woman who's very angry at her therapist and she and that anger that moment of anger because of a hidden secret that her therapist has learned about and only the lated Lee has this young woman learned about this hidden secret now she doesn't really know how to maintain her connection with her therapist let's roll that first film [Music] [Music] you they kept letter secret from you for a long time huh a long time it wasn't just a few weeks it wasn't just a few months it was two years Wow I don't think I realized that yeah actually probably didn't tell you that boy that's a hard place to be to have to make a choice like that I mean for you and it feels like as long as there's this power thing happening over those letters it doesn't let any of you have the chance to actually deal with it like deal with what happens next do you see her do you not see her do you I don't know what do you think it would be I can be unadopted hmm I think it could be pretty hard to be unadopted at this point no it's possible okay so let's say you got unadopted where do you go somewhere else that's a plan you gotta be in a lot of pain to want to give up a home I don't know I guess I'm wondering if you can imagine any scenario in which you could give a little give a little what and just a little be open to talking to your adoptive parents to trying to make it less rotten right now and why should I trust them I'm not saying you should trust is a hard thing to earn and they did some things that messed with that pretty big-time my guess is they did it with good intentions but that doesn't make it less of a betrayal of trust so I don't think you should just hand your trust over I think they probably need to earn it back from you but it's only going to happen if you give them a chance to turn it back I guess so I know it's a big ask I think I think your adopted mom is probably pretty willing to do some work with you I don't know yet what that would look like but we might be able to figure it out but you'd have to be willing to [Music] boy when I learned that Gabrielle's parents had held back letters for two years I was really taken aback I had not realized that the letters were hidden from her for that length of time and I felt like a long time to hold a secret from her it was a really tricky position when she talked about the fact that the letters had been coming for two years because I found myself really pulling for her to see those letters and trying to hold that balance between the decision-making I imagined her adoptive parents must have had but that wasn't what mattered in the room at that point I just wanted her to get to read those letters and that was without knowing her at all and not knowing what was in the letters and what the content was and how it would affect her but it was impressive to me that her biological mother kept sending them over such a long period of time I found myself not wanting to jump right into pushing for a meeting between gabrielle and her adoptive mom or her adoptive parents right away because I had very little sense of the dynamic between them I when I first meet a young woman and I don't know her at all and I don't know her parents at all and I don't know how safe or comfortable or productive that kind of a meeting is going to be but it felt in this session like we were trying to solve a problem here that existed somewhere else and like we just weren't going to get very far talking just me too Gabrielle unless her mom was in the room with us I found myself feeling anxious about what those letters might bring out now of course at this point all the effect that's coming up is about not having the opportunity to read the letters and in some ways what we imagine and what we anticipate is potentially so much more than what is but I couldn't imagine any scenario in which reading you know and I don't know how frequently they came but two years worth of letters from someone who you loved and you lost wouldn't bring up a tremendous amount of emotion and I think that Gabrielle is someone who has managed her life by protecting herself from emotion and from relationships and so having that sort of inundation in emotion and experience without anything to help her with that you know she'd survive it she survived a lot but boy it would be nicer for her to have some support in it Oh dr. blaustein you must hear selections but I want to ask you something right off the bat I think I counted five deep sighs from you in session that we just saw just in just in those few moments do you remember what was going on for you in any or all of those moments of so interesting that's so interesting first just thank you again for letting me be part of this process you know it's interesting because I don't know that I noticed it in the moment but it's in line with you know one of the things that I was very aware of which was her pacing and her guardedness was so contained and tight and my own sort of natural inclination is to move at a quicker speed and having to keep slowing myself down to slow my pacing to slow my rate of speech to slow my energy because I was very aware that if I move too fast she'd be gone that I might lose her and so it's possible that some of those deep breaths were just about that keeping myself sort of centered and grounded in the room in the moment and probably in some moments I succeeded and in some moments not quite so much but there is definitely an awareness that I had throughout my conversation of the need to try to in some ways not overwhelm her given her guardedness and I noticed that after each of your size you you did pause exactly as you're saying and that gave you and Gabrielle probably a just a moment to reflect but not too close and then you said several things that were basically identifying kind of the core theme the first one was power and control later betrayal and tress so I thought it's very interesting don't you think that after each sigh you you spoke to something very fundamental and to perhaps a tuning with Gabrielle and her pulling back and slowing down perhaps that also gave you an opportunity to focus in on what you felt were kind of the core themes that needed to be brought out and looked at yet potentially I mean I think that um you know one of the things I'm always very aware of when we have youth who are so guarded and self protective and you know in this case I knew somewhat coming in of her history of attachment losses and betrayals and something about the current situation no clearly not the extent of it it sort of pulls for this awareness of the need to see some of what is underneath that guardedness to be able to mirror the youth experience in some ways but in a way that is not so so pushing so hard that it shuts them down further because obviously that guardedness is self protective and you know it feels like you're kind of on a balance being the whole time in a session trying to walk that line between not pulling back not disconnecting and not coming on too strong and it I often find myself I think in situations like that trying to see and name more of those for themes and or more of what I see in the youth as opposed to focusing necessarily on just the content of what they're saying and I wondered whether apropos of what you just said Margaret did you as you look back were you aware of thinking that Gabrielle as much as she was saying I just want to be unadopted I want nothing to do with them they've betrayed my trust which of course is certainly very important and very understandable did you have the thoughts that there was that other side that deeper side where she actually really wanted to find a way to repair of this this wound and repair of this kind of fraying of the relationship with her with her absolutely I mean I think that one of the most painful parts of this situation that was that this had been for some period of time a very positive relationship at least was my understanding based on the history that I had going in and for this young woman who had so many transitions and so many losses to have that and then to feel it slip away you know the inclination for so many of these youth who've had multiple transitions and losses is good things end and one of I would hope goals that we have in working with youth and with families is that relationships can be repaired and it would make sense to me that this is something she would wish for and yet again you know I don't know that that's where she was at in that moment and so it was it felt important for me told that internally and to hold the possibility of it but not necessarily to throw it in the room although I do think you know I have to say one of my own observations is one of my least favorite moments of myself as a therapist there are two of them in a session and they happen to we'll make this clip in in watching this brief opportunity is when it she said something about maybe I could be unadopted and my response was to challenge that as opposed to hear it and I don't know where exactly that came from and myself and I think that I caught it and then responded in a more attuned way but boy I wish I had started with you know that's a big statement and you know to say something like that must suggest you know the depth of pain that you must be feeling and the other place was was when she didn't know where she was going to go I tried to throw out some humor and it just kind of fell flat and I don't know if those may have been moments that I was uncomfortable in the moment but there is this constant sort of I think awareness of the ways our own statements land or don't land and pull in or distance the the connection and and I was very aware of it with her so bottom line when you think back about that and I really appreciate your candor and your thoughtfulness about this those are those are reactions and thoughts that I'm sure we've all had as counselors and therapists bottom line did you not want Gabrielle to give up on her relationship with her adopted family and did you not want her to be basically out there alone if she had no place to go oh you know I absolutely didn't want her to give up that relationship now I think that I you know I probably early in this session was still working to align with her perspective and to mirror her experience that in some ways I kind of lost the alignment or was vulnerable to losing the alignment or perspective of the parents the adoptive parents in this situation and I think we got back to that towards the end of the session which which was here in this clip was towards the end of the session as we started to work towards the potential of there being some process and some repair or at least some forum for discussion with the adoptive parents but yes definitely I mean I think my you know I wish the wish in general is to support attachment and to believe that you know most of the I don't want to make a blanket statement but certainly in this case where you have adoptive parents who are really motivated to address this huge conflict that's hit their family and this young woman who's had so many losses the goal would be for this to not be another one and it would have felt very sad for her to have taken off and lost this opportunity and at the same time you know and this is where I wish I had heard her plan and not just challenged it the need to escape or to take off is such a valid one in this moment of feeling so lost in the West which is I think where she was add in that moment and when you asked her in what you called a big ask when you asked her whether she could possibly see a way that she might be able to begin to work this through with her parents were you also asking her whether she would give you a chance - interesting interesting I mean yes because this was our first meeting and I there is a level of trust of stepping into can I create a safe enough container for her to have some of these conversations with her adoptive mother and you know I was definitely I think she'll for much of this session as if I was on trial and had to pass this test this was just the very beginning of it you know in any good clinical relationship that continues over time with someone who's had such hurt over time and relationship you know the tests come over and over and over again you don't just pass it once and you're in and so yes I definitely was aware that this was an ask of her not just to give them a chance but to give me a chance to be a support to her in this process and maybe that's an important thing for Gabrielle for any client to know that you actually want that chance that it's not something you expect or demand or require but that it it's a choice that you're you're offering to her which came through very clearly a common an audience member I just want you to know saying thank you for sharing your reflections doctor blasting you were able to express my feelings and reactions regarding working with a quote/unquote guarded youth we you're capturing some thoughts and reactions of feeling some choices that are very meaningful to many of us I'm sure as I want to give dr. Susman and dr. Chang a chance to ask it or to offer any comments or questions for CEO bill sure you know I enjoyed watching this tape a lot because I could see that you working work at a real crossroads with her and that perhaps you were you were with the painter glommed in with her as possible really people who question whether she could trust you as well as them and then it was your pacing and the delicateness antenna cleanness in which you then proceeded in being you know careful knowing that things could go in bad directions you could looser and you kind of carved out I thought a nice way to kind of stand with her in a gentle respectful way in to hear her and what is especially likely that was very useful is even though she had shut down you began to narrate her internal process in ways that i season them to do with play therapy in which he just kind of observe and talk about what they're doing but you kind of narrating and articulating of series in the complex decisions because that might be going on with her offering those intended in a way that that was really helpful and I think that's a courageously to especially when you're not getting anything back from her but I senses you were getting at least passive assent that you were tracking with her I thought that was very powerful and if she might be a person who because of her past difficult experiences doesn't Monica her internal life or has very black-and-white judgments you're kind of providing a more nuanced Archie so what might hang on with her and then even in the latter part after you had you know validated at her scenes I think in how painful and difficult this is only then did you kind of offer the possibility of the more nuanced understanding of what her adoptive parents might be and giving her the option of heading to agencies in preserving her that she has choices here and I really loved watching work Margaret on this well thank you thank you that's nice to hear that I did keep feeling as if you know there is that concern of going so far into the alignment or the witnessing of her experience that you start to lose the perspective of the other humanize or say too many negative things about the parents I was trying very hard not to but it is a process of a balance so thank you really that's what I was going to say Margaret that I love to see the balancing act that you play here and how did you know we don't I do they were also trying to engage the Vienna letting them know what what your thought process was and he was very genuine it came from a very good place and that's when you started to turn her around by just giving your honest opinions about serious things that was happening in her life and without in the middle sort of marking big boundaries between you and clear adaptive science or you answer biological mother or between you and her it was 2d combined that you were sort of making a space for everybody who was really important in the life of this care what acknowledge it is to make make a space a psychological space as you said so so eloquently dr. Chang for not just Gabriela but for her biological mom and for her adoptive parents no wonder you felt as though you had had a lot of people in the in the room with you and you were trying to attuned all very true very very were aware of that makes it harder but it also probably made it possible for you to actually speak to and bring out that narrative that dr. Saltzman was describing so that Gabriela could every Ella could begin to listen to what she might be thinking and feeling that otherwise she might just have felt that she had to shut out mm-hmm well that I was wondering that when you are offering when she's not responding to much good on your offering that kind of extended narrative description of what might be going on with her is that kind of nerve-wracking for you like oh my god I'm getting this wrong I could be losing him looks like for you yeah you know it's a great question and I think um you know I I'm a talker and so that that moment of or those moments of exploring and thinking of what might be feel of all I think where it starts to feel really comfortable as you watch it land or not and you know I think I think what you said earlier around her nonverbal cues which are you know it's hard even on a video when it's facing her to pick up on it as much but sitting with her I could tell the moments when she was with me in the moments she I had lost her and you know and I think that's why you know I say when I watch this that moment where I she said something about being unadopted and I didn't go there with her I lost her in that moment and you know I found myself having to switch gears and switch tabs those other moments talking about her level of hurt and the wish and what she wished for felt like it landed and and so in that sense I think the worry again is going on for too long or putting too many words holding her experience for her without letting her be the holder of it especially given the protectiveness that she has of that experience in the fact I'm brand-new you know and is it even okay for me to try to witness or is that presumptuous I wonder if you were aware Margaret of actually reeling Gabriela back in with your words when you felt that you had lost her and then there were the times where you said it landed which I am guessing tell me if I'm wrong that those were times where Gabriela would actually she would shift from that kind of icy glare or looking down and not looking at you at all to a very intent kind of looking at you like and there were some yeah even like facial twitches but again I don't know how aware in the moment of the specifics of that I was but in watching it for now on this playback I can see those moments a little more clearly and at those moments just one other thing that might be interesting you those are often moments where you actually slowed down and you looked down mm-hmm most of what we saw you were looking right at her keeping that eye contact very not intrusive but very clear I'm here I'm with you but there with those moments where you pause you look down and then you came out with a thought or a suggestion or request yeah you know I was actually very aware of eye contact during this session I contacted such an arousing intimate thing and really modulating the use of eye contact giving her space in some ways in those moments where she came in and connected and then connection can almost feel like too much and sort of creating this opportunity to titrate that felt important in the moment and so I did find myself during the session feeling very aware of how much or how little eye contact I was using so one more comment or question from an audience member and then we'll have to go on we could talk about this for a long time it's very rich but we have two more very rich ones to come so an audience member said I thought one of the most significant moments was when you suggested that the parents would have to earn back their daughters trust that it wasn't a given mm-hmm that was at a moment at which you were trying to articulate something that you thought would be important for Gabriela to know that you understood from her perspective yeah you know I think boy Trust is such a big word and I think there's often this this over expectation that youth will trust us as providers will trust there givers will trust others and you know for for kids who have been through so many complicated layers of betrayal of trust it was very clear to me that Trust is one of those things that you're going for the just good enough and in this case the betrayal of trust from her felt experience was very clear and present in the room and the communication that trust is something that's earned and that she there is no expectation that she would turn that over for no reason because to expect her to turn over her trust is to say these things that you've done to protect yourself all these years aren't necessary and yet they are right to be aware that trust is something that you have to work toward at the same time I was trying to not stay it in a way that said and your parents did something terrible so staying with her experienced in her perspective as opposed to meaning it from the lens of a of her adoptive parents and their choices what if another balancing act that was too an emotion wandering I am also wondering my very if it was also the importance of from allowing the adapted buyers to claim her back you know after this big break that they had that that may be the beginning steps for bringing back the trust was um very constraining her bagging on their adoptive daughter because meaning in English is what he was going on with Gabriela when she found these letters he was somehow somewhat her biological mother was actually blaming her women to back and that feeling was actually as such a symbolism for that we are longing this for that deep connection that somebody is really wanted her great great yeah for sure and it's such a pretty situation she's in because she's immediately put into this place of split loyalties between her biological mother and her adoptive parents and you know how meaningful would it be for her adoptive parents to show a willingness to work that at her engagement with them mattered to them and I was pretty sure that they were willing to you know just based on my back history of you know entry point conversations with them well a very again a very rich few moments there's a universe in several grains of sand here so thank you very much dr. blaustein and and dr. Saltzman and dr. Chang let's take a look at another challenging session in this case it's dr. Saltzman who was meeting with a young man who feels that in some ways he has no exit he's trapped by a very unlikely perpetrator and this is something that his therapist will just discover for the first time as we watch the film [Music] I just feel really done with it I feel really done with the tutoring and I feel really done in the therapy okay so both of these things are feeling like oh I have to go or your your parents or your parents making you go to the the - tour - okay well because they think that I'm gonna start doing better if I keep going to the tutor but it's like I started doing a little bit worse and then I got the tutor and then the more and more they pressure me to do that like I just kept doing worse and like all these things aren't helping so I think I might as well just not do them anymore so you're ready to be to pull the plug on the the tutoring for sure and you know possibly here and we'll certainly go with what feels right to you I want you to have a voice and in all these decisions you know not just you know the parents saying okay you have to go down here so certainly if we need to ramp down here I'm good with that and I'm happy to work with you on that there's a mostly your parents a lot of it is my parents but I would say like my tutor makes things pretty bad too how does she do that she's just kind of like - - personal ID how do you mean does stuff that the tutor shouldn't do our last session she she actually put her hands on me I told her to stop but she kind of took my whole backpack off my bed and then she sat down beside me and started asking how I felt about girls and then she was rubbing my back and after that she just might had both of her hands like one of them was on my leg and the other was on my back and she was just rubbing my back and then she told me that I'd have to see what it was like with her so that I could understand if I liked girls and having sex with girls and I just shut down and I told her to stop it and that I just I didn't want it anymore and then I got off the bed and I walked across the room and I said I don't like this but then she told me that it wasn't a weird situation and that I was not allowed to tell anybody about it and I'm really scared that if I do tell anybody about it she might reveal some other stuff that she's gotten me to say to her that um I'm just not ready to be out there and I feel like she really has me trapped Wow thank you for sharing that that I I can see why you would feel trapped and confused and maybe even panicked about what's going on does it is it clear to you that this is this is an abusive situation does it does that register with you I know [Music] you know as I think back on this session there's a couple of opportunities that I did take and some that I didn't take ones that I did you know I think you know when he first came in and he said okay I'm done here i I I went with that I thought that was important you know and and moving to the theme about you know it's important that he has his voice and that he can you know say what he wants outside of his life but certainly here in the sessions I thought that was a good direction well you know it took me a while to adjust to the the the intensity to really fully realize how present and intense the abuse was here and oh I think very importantly is the way that his was worried about how that was gonna play out I think he had a sense that we were moving to somehow in order to stop the abuse in the turn in situation I'd have to speak to his parents but I think he did have real fears about how this was gonna play out you know when the word got out and even with in terms of personal information being released I wish I would have spent more time in the session you know talking perhaps about those concerns and how we can put in place safeguards in terms of the conversation with his parents but also with the larger world Oh dr. Saltzman I'd like to start by asking you at the moment where when you realized that this young man was being molested by his tutor and you said feeling that he might be feeling trapped what was going through your mind and what were you feeling nice I did I what I was he when I said get a sense that there was a real abusive thing going here you know we've got that part of our voices or an internal antenna you know as many reporters at floud this is strictly a 100 year and you start to go get schooled in to this because there's kind likely a specific protocol it happened following look out for I was it kind of your heart starts to be a little faster Eagle they get a sense of not only the possible gravity of what happened but also the sense of this ongoing possible correct and if you have to the priority 50 suddenly so it's kind of good I had to slow myself down I know if you saw me but I kind of go it's kind of like a whoa and you gotta slow myself down so so that I increase so that I don't overreact right which would be Betty exclusively also you flip into manually reporter on here or are really kinda react either so which is not to show not to fear the seriousness and gravity this so trying to find some more work they're both is my just my physical expression as well as my voice so that's was the challenge for that I don't know if you saw it but because you were right there in the session and then watching it again course you're going to be reliving it but what I saw at that moment as your facial expression your look went from being very kind of accepting and open to being very focused and sharp almost like at the moment you had a reaction like how could this tutor possibly be doing this I wondered if that did any of that go through your mind at that moment yeah it did I feel like the the level of the krail you know it's such a push my own buttons and you know my outrageous whereas she's going on and then I a kind of a protective thing that's going on to the eye between must be I think that's right I could even have already mentioned I could see my eyes ago whoa you know and I can look more much more intent to it I hadn't moved in and I tried to convey I had a manage back and I hope I backed that off a little bit but it hadn't I hope I kind of know we used that in a productive way well I don't think we could see exactly what your clients reaction was then but he had been breathless right up to that moment as he was just starting to finally let this out he could hear him breathing and having a hard time with just getting his breath and then what I recall seeing as the session continued we couldn't quite see it here was that he locked in on you I contact and his breathing started to slow down and that means I think that's probably what you're what you're talking about and that probably wouldn't have happened if you hadn't have kind of gathered that intensity in that moment and contained it right you like it kind of you could two-step dance there one is two give the respect due to that this this is a powerful thing he's experienced any level of pain or panic and really you know fear about what could be coming from this and this might be the first time he's sharing this so the first part is to kind of validate that and hear that and to feel internachi's intensity and he and then to provide a frame for it in a sense and which again that is the abuse frame they have done so quickly I don't know but you know this idea that he's also might be dealing with questions of did I invite this am I to blame you know in my batter you know what a person Twitter so I wanted to mean in a clear way in that way but I think he in the longer version we do have a sense that he feels that you know I'm not happy and I hope they I'm trying to be on my side his ally illness into the door kind of theater and I think you're telling us something really important here because you just described how you were aware of the potential narration that he might have had that Adam might have had going through his mind about this very complex and very disturbing set of events his part in it his responsibility what choices he had what choices he could have had what he could have done should have done you were clearly aware of that complex narrative but at that moment you also you chose to focus right in on helping him to recognize that this was abuse and that something needed to be done and that you were there to help him do that right into provided preservative agency at all possible his voice may be anything else one of the things that it might have come up you know earlier or in the work is that for him to have a boy but he's not a passive victim of business with India and you clearly set the stage for that and of in the early part where we saw that you rather than saying oh no I'm sorry you really need to keep seeing me in therapy and we're not done yet you said okay you feeling that you need to ramp down on this squeeze that's something that we can look at and we can figure out how to do so you had already given him permission to make a choice even if that choice meant that he was pulling away from the therapy yeah exactly and I've had to deal with that different situations when I worked with very very distressed that kids in day treatment in which they can be very even much more strongly rejecting and angry and you've got to kind of push the clutch in on your own possible feelings about that and and write with them and yeah that's the challenge there I'd like to see if dr. blasting and dr. Chang had some observations or questions for you sure you know this is this is Margaret and you know though I have to say I was so um drawn in by the sort of intensity and solidity of anchor that you provided in the room you know the session took such a sudden right turn and you were so present from the beginning but as he started disclosing and it became suddenly clear where he was headed with this your presence felt like such this necessary grounding force for him you know if he goes you can see him starting to go more and more internal and his eyes shifting and it felt like you were so solidly with him that had that not happened he might not have been able to finish telling his story and it was such a you know subtle the presence the way your present sort of shifts but it's palpable it was interesting I don't know if this was a purposeful thing or or just the way it sort of emerged but I was so struck that the first vocalization the first vocal moment you had during the course of his story at least in this particular clip that we're seeing is when he's describing saying to the tooth I don't like this and it's just like powerful moment that he has and you release from sir I don't know if you said yes or something but it was something that was with him and it was such a lovely micro moment in his story and I don't know I was struck by that and watching it and it was a very clear yes right no yeah no yeah I think that that I think that is right in my intent is he is to dis is your same as to this could validate what he is experienced no the producers tried to almost Gaslight him well in that situation and as you know there's a back history that I didn't know over the idea of the time of a previous victimization in which he's not trusted his perceptions or any views so very clearly decision saying it take that feels like the right direction is to really validate their way to the note you're right you know yeah member yeah yeah that moment just felt so powerful and empowering in a way that I think allowed him to continue and shifted you know as he's talking through this victimization place suddenly he's anchored in his voice which is something you spoke to that you were able to continue facilitating throughout the session so it's just it's lovely to see how such a small moment can provide that opportunity one thing that could slip by easily but really deserves very careful attention that's great glad you pointed that out Margaret dr. Jack the importance also of self-regulation the media I think that for me when a client tells me that they do not longer want to continue with therapy it takes me a little bit to just come be in the room and he go back and see and you know I stopped my heinous dialogue about okay what did I do wrong no maybe another therapist come see him and he would he or she will do better than I or things like that but but you were just like Julia Margaret were saying it was in the room you stayed with him you didn't shorten decision you wanted to know more about what was going on and allow him to have this choice and that make such a big difference jeez yeah thank you I agree with you having that that is exactly the right way to respond with that and then to provide an opportunity to explore what might be underneath that right it's such a complicated issue but being wanting to be done with therapy and you know this is a waste of time but then paper should go with it and then that takes the stomata maybe they come in with built-up kind of you know like you know I'm going to save this thing and maybe written fearful of having said it you okay okay that's fine that's acceptable and then let's look at what what what's going into this you know and did you have the sense bill that when he said when he disclosed what was happening with the tutor that at that moment did you have the sense now he's telling me what he's definitely needs to be done with Wow God is a nice way to put it yeah I might not have I don't think I put that together in the moment just think about a guy think that's right that is you know that was really the big thing that he's really done with the damage and all the hurt that goes with that and then maybe the leisure small part of it the fun edge of that was to talk about you know the therapy situation or the tutoring situation in terms of the obligation but then once he it's like people give you like these small little gateways that is so easy is like you terribly got that first thing see how you react if you kind of passed that test but that's okay then you've got opening to maybe to go to the bigger thing and that's why often we get in later in sessions reading multiple sections down the real issue comes out and actually you write I think that is wiki is done with and that he wants to stock and you know for you to articulate that so clearly in the way that Rocio and Margaret of both commenting on non-verbally as well as the words that you chose that gave him the choice that talked about how it's important for him and but it's something that he can do with your help that's exactly what probably would be the one of the hardest things for a young man or a young person of either gender to believe if they've been revitalized and so here we have as you said here the young man who experienced sexual abuse earlier in life something that you as a therapist will come to know later and of course now having it happen again a sense of powerlessness the sense of self blame all of those kinds of developmental trauma reactions are exactly what could get in the way of him feeling that he has any way to to be able to actually stop this and you're standing with him in saying that though there is a way and we can do that together yeah I think that's the direction why I would have liked it to be hopefully we started that that's the right direction there is a passivity that we often see photos in you that have had you know anything but especially multiple types of the victimizations which they feel that things are out of their control in that way and so that is that type of empowerment or recognition you know they're they're warmness you know that they can do is key you have their role in recovery and in being able to actually protect themselves and be with people who value their safety rather than people who unfortunately might exploit well I want to I want to share a comment from the audience although then this is a comment i'll just read although a short clip the session felt full of interaction and connection i felt that your clarification questions build trust and rapport and allowed the young man to share now a question for you bill from the audience member how would you have approached reporting the tutor or developing a safety plan right you know um i would be in the session i would talk about you know first i would want to hear really hear his concerns he has a lot of complains about you know how this might come out the things other people might hear how his parents will react so i really want to give a allowed and I'm trying to share all those things and then i do want to provide information about kind of the requirements all the legal requirements in the situation but how we can together you know we meet those requirements but also maintain some of his voice and again his agency as well and how we can do this together so usually we would work out a detailed plan almost step-by-step about who we contact what what this will look like and what you can do so I don't you know so I don't I don't I can't I think I just said that detail plant has to be worked out in a concrete manner so that he can feel that the hair that any value illegal down to know exactly were going but it will act be collaborative informed by both his concerns and also by my my sense would have most helpful but also believe issues so in some sense what we saw in these short clips are you laying the foundation for that collaborative work that could then lead to a plan and actually protect this young man safety I hope so yeah yeah well thank you that was again a very powerful brief moments from a session and a lot to think about we have one more dramatization and this is a client where dr. Chang is talking with a young woman who might be thinking something like I can't face what I can't remember let's watch the clip [Music] you he's scratching how do you can we split other ways to so I can see that you're moving your feet can you feel your feet on the floor Sam yeah can you tell me if you feel warm or cold yeah let's try to keep on moving your feet keep on moving them can you move your other foot all right can we breathe a little bit more let's do three times this time okay one two three instead of scratching can you touch your other hands when you're born like this how does that feel can you feel the oil can you feel your risk keep breathing during a safe place and nobody's trying to hurt you here okay I like this do you feel that your body likes it nice when you try to suit yourself later how does it feel nice nice [Music] obviously Samantha came with great strengths right she was a good athlete she was a she is a wonderful student so you know I really wanted to use those strengths in order to help her overcome this terrible event that happened to her that was one of the pieces that I really wanted to make sure that I could use even in the first session so you can help us in the other sessions that could be a little bit tougher than the first one when Samantha began to suck her thumb first I thought you know clearly I'm the ountry goering her this is something that she doesn't want to talk about and I was it was helpful for me to know that at least you have found some ways to cope with it right so I wanted to make sure that made sure that I could let her know that ice I was seeing it that I knew that this was helping her and I also wanted to make sure that I could at least add a few other things that she could do besides the sucking from the second hurt Salomon on you know touching her ear I told her Martha that I would do it with her I will try to move my feet and also touch my arm my hands because I wanted her to know that she wasn't doing it alone that I could do it with her and we can do it together [Music] [Music] [Music] [Music] Oh dr. Chang when you asked Samantha if she could feel her feet on the ground could you feel your feet on the ground well you know I tried as much as possible to also feel my feet on the ground I was seeing how this stressful it was for Samantha to be in the room with me and I was very conscious that it was my first session was there that I really wanted to stylish good rapport and good engagement with her just to make sure that she will give me the opportunity to see her again in you know what happened to her month - Samantha was very recently and clearly there was a lot that she didn't know also there was a laughter but another was left for her to figure out so I needed to talk her down herself a bit more I saw that at times she was actually um vulnerable to leave the room and I just wanted to make sure that she felt a bit safe on a little bit more at the time and that you know that I could instill a little bit of hoping that we could work together in something they difficult for life this is a kind of a rhetorical question because I think I know the answer but I might not but when you did the breathing with her when you grounded yourself by feeling your feet on the floor when you touched and stroked your hand and arm in a way that was gentle rather than hurtful were you doing that just to get Samantha to do this or were you actually doing that in a way that helped you to feel more regulated yourself this was truly atonement with my own instant my own set of need for regulating myself and connecting that I was really trying very hard through to help track or regulate at the same time so I was dancing with the Manta but I also needed to dance with my own needs of of not going into places where I would I could not feel so blessed or I could feel that I was not going to be able to just revise a month or what she needed at the time and you know what we didn't see in this clip of what you had heard as a therapist was that Samantha had begun to talk about a horrible situation where she had been gang-raped very recently and knowing that and then seeing Samantha go into that kind of dissociative State were you were you worried that she was going to go so deep that you weren't going to be able to help her come back that definitely was in my mind and it was really hard to engage her in special Samantha didn't talk much and I didn't I was very aware that I didn't want a so many questions I just wanted to make sure that I could be with her and definitely making sure that you um wouldn't leave me wouldn't leave the room and you wouldn't associate clearly even the fact that she was in this session for the first time with a complete stranger while creating a big distress especially because she knew what why she was there did you notice as you as you watch this clip that you you never lost I contact the Samantha even when she wasn't making eye contact with you and you could you see also the way in which you were looking at her with such genuine just caring and compassion but not not in a way that was like she's a victim but more just the lovely young woman who as you commented in your observations after the session clearly you were seeing this young woman for the whole person who she is not just as a victim or someone who is going through a very deep deep state of pain definitely I mean I did mean it that I started learning a bit more about Samantha I learned very quickly that she had wonderful strengths that she was a very resilient young woman that she really were very far for what she got you know going to private school doing very good in school and you know having big dreams and my high was going out to her because definitely you know this level of abuse of betrayal by people who she knew was I could only imagine how hard it had to be for her even just to learn about it and then going through the whole process of going to the hospital and learning more about people who were just talking to her about what happened so so clearly you know I was seeing very strange thing I was also seeing there actually struggles and I needed to balance my own inner conversations about you know how not to lose her how trying to figure out where we could start making legal sort of things to connect electing with her how I could really suffer to feel some calls for to know that where we were it was a safe place so I was going back to the bases with Samantha to start building a foundation where she could start healing from the terrible event happened to her and also to start reclaiming her life and her dreams oh that's what you're telling us is very important because what we saw was you as a therapist being very quiet very gentle very present and just staying with Samantha and helping her to gradually shift so that she could begin to be more aware of herself and be able to help herself feel soothed as you said meanwhile what we didn't know was how much was going on in your mind you were thinking through all these complexities I think that's a really important point for us all to be aware of that well it seemed as though you had one thought which is just how can I be with this young woman and help her be safe and gradually stay in or come back to the session you were also thinking about the history you were thinking about the current incredible shock that she had experienced and the layers of that shock and the future well I want to mention that we got a shout out from one of the audience members for the actors and I think that we all agree that they were quite remarkable but the audience member also wants to thank you dr. Chang for demonstrating the grounding techniques so so clearly and beautifully and at the end of the clip the audience member said it was clear they felt that they could see Samantha returning to you and that's that's the the really crucial thing that clearly was on your mind as well question from the audience for you and then I want to bring in dr. blaustein and dr. Saltzman - would these kinds of grounding exercises do you think that they'd be helpful helpful for younger children as well I think so but I'll always follow the child's lead you know there are some young kids who made me work extra hard and I you know I can dance a little bit with them or I could follow some of the steps of things that they want to do to ground themselves so usually in my experience is a little it requires a little bit more of energy but but it's equally I'm careful to start assisting younger kids to begin grounding themselves during the sessions and to take that into other places as well that's a great it's a great reminder little kids have their own ways of grounding themselves and sometimes we as adults have to be very careful and very good at servers and be willing to join the Big Dance rather than have them do our dance that's that's very nicely good well Margaret and bill do you have observations or questions you'd like to add and if you do you'll have to unmute yourselves hi yes um you charvel me haha I think most of what I'm just sitting with is Rocio that was just such a lovely that's a lovely session watch just that that brief clip of your engagement and interaction with this young woman and you know if there was really honestly just such brilliance in the way that you start with her and engaged with her I love how you followed her body's lead so that in this day of overwhelm and dysregulation you weren't introducing all sorts of you know various new grounding techniques you were looking at what her body was already doing to keep herself grounded and you were heightening her awareness of those strategies which would do the least harm and the most help and then engaging them with her and you could see her body start to shift and it was just it was really beautiful to watch thank you thank you it's really telling me to stay in the moment so um you know it took me a little bit to follow her because I really needed to just face my own dysregulation and my own sort of fear that I was going to lose her but as soon as I started focusing on orienting myself into a therapy station and into what she was offering to me that was a little bit easier every time you both came back into the room yes that's a wonderful thing and that that's the elegance as marker to say bill did you want to add you know I want to they're checking with Rochelle and asked but you know my guess is that when you're working with their primary just know a little bit about the level of trauma or and I said oh you're on a work for possible kinds of dissociation and then you should use it to go to a brownie when you guys need it I mean it is something to me you all ready for it all kinds of though other signs of dissociation that you still oh I got my parties and go like to round anything yeah a depends on what your client greens to the session what sort of intervention you will use in order to help them come back to the room in my might take first is whenever I see some signs that indicates to me that my client is a bit burnt venerable and my have the potential to dissociate in doing the station I definitely take the approach of stuff sort of using some techniques that I I see helpful if I know my client for a little bit longer I would already know what are those things but if I just started getting to know them then I really need to learn quickly about what they are offering for me to start using what they um what they show me will be helpful mm-hmm yeah I got that entity really customize how you take this individual yeah I think I really enjoyed this watching you work Rocio is just even though you shift gears to a brownie pecking again before you paint is this a kindness and support of questions that you have that is so great in it then it kind of plays even though that there's you know the client is is having a strong reaction might be really really destructive good you can kind of a kind of any a quick liqueur being in a framework that this is a cooking perspective you understand that the scratching makes sense to you it's like the introduction you drink leaving a working surface and individual respectful way and usually safe setting yeah you can't be x squared plus four year the place we would simply unlikely works so they're the first there is that kind of and understanding acceptance I'm wondering easy there's a sense of your heart being present with this client at all times regardless of what he does but I think makes of all the shift in which he really sleep increasingly thoughts you'll see and from that well thank you that's so sweet bill um I I definitely even though I met this girl for the first time I think that I I I was able to connect very quickly and I needed to balance I didn't really want to connect just with her suffering but also we all the strength and the resilience that she she has so I think that that really allowed me to to balance myself and to be very genuine and state present for her and I waited you know in the way you introduced that bill so how does this feel and go I like that you know it's like she has ownership of that of that expanded coping strategy it is the third choice you know who needed you scratching to gentle rubbing that I did you also establishing the basis that this is her ownership of craft a new repertoire different way of dealing with this distress yeah I really wanted to empower her you know what happened to flat that was terrible so I really wanted her to claim bastard power and indeed all the steps well I think we've we've had three really wonderful remarkable examples of how in just a few moments critical moments in therapy it's possible for a therapist a counselor a helper to communicate so much to a client in often the state of extreme distress and that kind of quiet strength and compassion and the heartfelt desire to know the client to appreciate the client for the person that she is are here and I think that that came through in all three of these dramatizations and I know they were very real sessions for each of you as therapists and I want to thank you or the remarkable work that you're doing and and for all of your thoughts and your reflections which tell us so much more about what's going on inside which that's that's where we ultimately need to go well our time is up and I want to let Michelle do some closing comments but thanks again to all three of you and thank you to the audience so glad you could join us Michelle thanks Julian this concludes today's webinar I'd like to thank all of the panelists as well as the University of Connecticut center for treatment of developmental trauma disorders for sponsoring this event I'd also like to thank each of you for joining us please remember to log into the NC TSM Learning Center and complete the C e post-test for your C e credits and please be sure to join us for the next webinar in the series on Thursday September 27th at 1 o'clock Eastern Time 10 o'clock Pacific time entitled a spirited conversation PTSD and developmental trauma disorder pros and cons and that will be with jean briault julian ford and michael sue vac and moderators will be dr. Rocio Chang and Isaiah Pickens so thank you again for joining us today and we hope to see you again in September