Expressive Therapies for Affect
Regulation with Trauma Survivors
Lisa Ferentz, LCSW-C, DAPA
www.lisaferentz.com
lisa107107@aol.com
410-486-0351
When children have emotionally available and consistent
caretakers, they develop secure attachments.
Healthy attachment equals affect regulation (the ability to
mange one’s emotional states). They first inter-regulate and
then auto-regulate as they internalize positive soothing.
The lack of good attachment leads to affect dysregulation
children who are not allowed to
successfully attach have chemical systems
that don’t develop normally, and as a
result, they are in a perpetual state of
physiological distress.
When clients have affect dysregulation
and can’t manage their emotional
states, doing trauma retrieval work
leaves them vulnerable to flooding
and de-stabilization
Clients need to function in an “optimum window of
arousal” so they can tolerate and handle anger,
sadness, and other difficult emotions and thoughts.
When clients are NOT in this window, they will
present as either hypo-aroused (freeze, feigned
death) or hyper-aroused (fight-flight).
In either of these states, they are in their limbic
systems and NOT in their pre-frontal cortex. As a
result, they are incapable of insight, self-awareness
or the ability to process and integrate new material.
affect dysregulation: not in the optimal window of
arousal
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HYPOAROUSAL
Flat affect
Numb, detached
Passive, submissive
Victim identity
Avoidant, withdrawn
Disconnected from
body
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HYPERAROUSAL
Easily triggered
Psychomotor agitation
Hyper-vigilant
Separation anxiety
Rejection sensitivity
Emotional overwhelm
the foundation of treatment
(L.Ferentz, 2006)
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creating safety and a safe place
strategies to address affect dysregulation
pacing and anchoring for stabilization
containment to prevent flooding
connection/attachment to resources and
significant others
safety
• creating a context of physical and emotional safety
during sessions allows trauma work to feel
reparative rather than re-traumatizing
• “feeling safe” as traumatic experiences are
explored helps clients to differentiate between
“then” and “now”
• teaching clients to ask for what they need to be
safe increases their sense of empowerment and
control
safety
• clients often need to be convinced of the value of
incorporating a sense of safety into treatment, as
feeling safe may not be normalized for them in their
daily lives
• clients often want to move ahead before safety is
established, unconsciously re-enacting a lack of
safety in the past
Using the metaphor of pre-maturely jumping
into the deep end of the pool
• without reassurance that there
is water in the pool
• without checking the water
temperature
• without wearing a lifejacket
• without checking to see if there
is a lifeguard on duty
• without reassurance that they
know/remember how to swim
therapists and clients should work together to
assess and create both external and internal
safety before trauma work begins.
external safety relates to the dynamics within the
therapy room, internal safety relates to the client’s
“felt sense” and subjective inner processes.
creating external safety
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room temperature
inside/outside noise
physical proximity to therapist
arrangement of furniture
changing seating
use of artificial and natural lighting
phone ringer off/on
creating external safety
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visual distractions or triggers
objects for anchoring
agreed upon time limits
agreed upon use of comforting physical touch
use of pillows/blankets and other comforting
objects
• verbal/non-verbal signals to communicate “stop”
creating internal safety
• using soothing breath work
• inward focus with safe space in front of closed eyes
• visualization and collage of real/imagined “safe
place” (activate the 5 senses)
• visualization/collage of an inner protector
enhancing internal safety with breath work
-E,I,E,I,O
-inhale 4, hold 4, exhale 6: add words
-inhale (to top of head) say “I Am”, exhale (through feet)
say “here”
-inhale- close fist, exhale- open fist
– hand on forehead/hand on heart
– hand on belly/hand on heart- add figure 8 rock
Debbie’s safe place
• a small, white boat with comfortable blue padded seat and
a soft pink blanket
• covered in a shimmering silver net
• anchored in clear, aqua water
• gently rocks back and forth
• the sun is shining, warm. There is a cool breeze
• the air smells and tastes salty
• there are sounds of water lapping the boat and birds
overhead
arousal modulation
• trauma survivors react more
intensely to stimuli
• once arousal is activated, the
traumatized brain does not have
the ability to calm itself
• the deficit regarding self-soothing
is also related to a lack of
attachment in childhood
Hand in Hand Meditation
re-connecting with sensation in the
body is one way to pause, re-ground,
and modulate emotion
EFT: emotional freedom
techniques
incorporating tapping
EFT: Emotional Freedom Technique
Gary Craig
• based on Chinese meridian/ acupressure points on
the body
• identify a negative feeling/something that is
bothering you
• notice where you feel it on your body
• rate the intensity from 1-10
• name the feeling
• the feeling is “nervous electrical energy” that is stuck
on the body
• tapping “cleans out” the blocked energy
EFT protocol
• “set up” by starting with “karate chop” point and
saying, Right now I feel______, and I deeply and
completely accept myself”
• continue to focus on the feeling and pair it with
remaining pressure points on the body
• rate the level of intensity
• continue to repeat the sets until the intensity
drops down to a 1
“anchoring”
(Babette Rothschild, 2000)
• a concrete, observable resource
• a person, animal, place, object, activity that gives
the client a feeling of well-being and relief
• something that can be recalled with all of the
senses
• used as a “braking tool” when therapy becomes too
emotionally or physically arousing for the client
• allows the client to address charged material by
preventing the escalation of hyper-arousal
examples of anchors
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a small, smooth stone
a picture of a beloved family member
a brightly colored seashell
a favorite sweater or blanket
a stuffed animal/ a doll
silky colored scarves
pressing fingers in the “OK’ sign/yoga pose
a rosary
a wedding ring or other jewelry
a travel postcard
hand on stomach while breathing- VAH, YAH, RAH
aromatherapy- candles, lotion, teabags, perfume, etc
When we learn to drive a car, knowing how to step on the
brake is as important as knowing how to step on the gas
pedal.
The same is true when we work with trauma. Teaching
clients how to “step on the brake” and slow the process
down, so they don’t become overwhelmed or flooded, is as
important as showing them how to move forward towards
healing.
the soda bottle metaphor
(Babette Rothschild, 2004)
As the client begins to access trauma material, attention is
paid to their level of hyper-arousal and the activation of the
sympathetic system.
Rather than allowing for an escalation of arousal, we
temporarily “put on the brakes” by re-introducing the
anchor, tapping, doing brain gym, breathing, moving the
body, heightening external safety and/or returning to the
internal safe place.
This brings the client back to a safer, less aroused state.
Toggling back and forth between arousal and safety allows
the client to proceed without becoming overwhelmed.
pacing with “scaling”
• create a subjective template from 0-10
• 0= feeling totally neutral, not disturbed by emotion or
memory at all
• 10= completely overwhelmed by the emotion or memory
• ask client to identify the thoughts, feelings, body sensations
that accompany 0-10
• agree to “put on the brakes” when a client reaches a “5”
(or whatever number begins to feel unmanageable for
them)
“containment strategies”
• reassures clients and therapists that “emotional and
cognitive flooding” will not occur
• helps clients feel a greater sense of control over their
trauma material
• strengthens a sense of boundaries
• introduces notion of “working through” without being retraumatized
• increases clients’ abilities to return to the “outside world”
after session and function appropriately
containment
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turning affect/trauma material into colors and shapes
putting the color/shape into another internal container
checking for an inner sense of safety
adding additional layers of containment, if necessary
Sara’s containment for RAGE
• large, bright orange sun with jagged red edges
• absorbed into a dark wooden asbestos box
with a lid and carvings on it
• black braided rope tied around the box
• cover the box with a scratchy, grey woolen
blanket with red stripes
• cover the whole thing in shimmery, silver
angel wings
Mark’s containment
• emotion: despair
• shape and color: black, lump of coal, the size of a
large fist
• container: bury it in a swimming pool filled with
white sand
• additional container: heavy, black tarp covering the
whole sand pit
• additional container: braided ropes to hold down the
tarp
• now it feels adequately contained
containment
• making a collage or drawing internal “containers”
to store affect and trauma material
• writing down untenable emotion or trauma
memory and storing the paper in an actual
container ( a purse, a box, an envelope, a
tupperware container, a drawer with a lock on it,
etc.)
Somatic resourcing:
using the body for containing
(Pat Ogden)
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taking a breath
expanding the chest
re-aligning the spine
putting both feet on the floor
standing up
re-distributing weight on the floor
pressing crossed arms against inside of thighs
warrior poses
one hand under opposite armpit/other hand on opposite forearm
thumb hold
Ericksonian flashback halting technique
(Milton Erickson)
• client assumes comfortable upright position,
both feet planted on the floor
• identifies, out loud, five things they see in the
room, five things they hear, and five things
they feel
• repeat pattern, identifying four of each, then
three, two, and one
• this helps shift awareness from senses
associated with flashback to present-focused
senses
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additional work with flashbacks
(Lisa Ferentz, LCSW-C, DAPA)
As I experience this thought/feeling/ body
sensation/image I realize I feel ______ years
old.
This tells me that I am having a cognitive,
emotional, somatic or visual flashback
I am being given information back about how I
used to think/feel in the past.
In the present, I can use this information to
grow and heal.
In the present I am strong, safe, powerful
attachment and external support
• continue to work on non-verbal attunement
with client to strengthen attachment/ trust
• assess for connection to external resources for
support: spiritual, 12 step meetings or other
support groups, extended safe family
members, colleagues and friends, 24 hour
hotlines, appropriate Internet support,
remembered resources
Working with clients who have been traumatized is a
balancing act. Always honor and empathically
process their pain while continuing to suggest that
there is a light at the end of the tunnel.
Timing is essential- it may take certain clients longer
before they recognize there are potential “gifts” and
opportunities for growth in their painful experiences.
Self-Report Questionnaires for Post-traumatic Growth
The Posttraumatic Growth Inventory (PTGI)
Tedeschi, R.G. and Calhoun, L.G. (1996) Journal of Traumatic Stress, 9, 455-471
The Posttraumatic Growth Inventory for Children-Revised (PTGI-C-R)
Kilmer, R. P., Gil-Rivas, V., Tedeschi, R.G.,Calhoun, L.G. et al (2009) Journal of Traumatic Stress,
22, 248-253
The Psychological Well-Being-Posttraumatic Changes Questionnaire (PWB-PTCQ)
Joseph, S. Maltby, J. Wood, A.M. et al (2011) Psychological Trauma: Theory, Research, Practice,
and Policy, 15, 1-9
The Stress-Related Growth Scale (SRGS)
Park, C.L., Cohen, L.H., Murch, R.L. (1996) Journal of Personality, 64, 71-105
The Personal Growth Initiative Scale-II (PGIS-II)
Robitschek, C. Ashton, M.W., Spering, C.C. et al (2012) Journal of Counseling Psychology, 59,
274-287
The Thriving Scale (TS)
Abraido-Lanza, A.F., Guier, C., Colon, M.R. ( 1998) Journal of Social Issues, 54, 405-428
The Silver Lining Questionnaire (SLQ-38)
Sodergren, S.C., Hyland, M.E. ( 2000) Psychology and Health, 15, 85-97
Using a remembered resource:
Visualize someone from your past or present,
alive or deceased, who truly believed in you
and loved you. Imagine you are sitting
together in a safe, comfortable place. What
advice would they give you about self-care?
What would they tell you about your capacity
to survive your pain and heal? How would
they re-frame your negative experiences?
Encouraging clients to creatively
document their growth through
self-made videos
Encourage clients to use inspirational
messages as screen savers on their
cellphones and laptops. This offers
ongoing reminders of hope and resiliency.
It helps clients to be their own best
cheerleaders!