So often as clinicians we attend trainings which are solely focused on learning ways to help our clients. We leave armed with a plethora of new skills, but what about us, the helpers?
I have just returned from three days of training in The Trauma Resiliency Model (TRM), developed and adapted by Elaine Miller-Karas, LCSW. TRM is a useful set of skills not only for clients, but also for those who help them. TRM teaches skills to help adults and children cope with traumatic stress reactions, and it can be used by anyone as part of a wellness practice.
The goals of TRM are:
- To deepen the “Resilient Zone” so one is better able to adapt to the stressors of life with flexibility and decreased traumatic stress reactions.
- To provide self-care.
- To help reset the nervous system.
- To reprocess traumatic memories.
For both children and adults, traumatic and stressful experiences can produce a biological process of dysregulation that is self-perpetuating, even in the absence of ongoing external stressors or threats. Although insight about life experiences can be helpful, it doesn’t always bring the nervous system back into balance. Consequently, symptoms of nervous system dysregulation cannot be “talked away” but they can be “sensed away”.
Learning to stabilize the nervous system by managing sensations is at the heart of the TRM model. The nine skills of the Trauma Resiliency Model, outlined below, can be used singularly or in conjunction with one another. As Miller-Karas says, this is a forgiving model. If one of the skills doesn’t work, try another!
- Tracking: refers to the practitioner’s and client’s monitoring and reading sensations
- Resourcing and Resource Intensification: using positive or neutral factors to create non-traumatic sensations
- Grounding: being fully present in the moment
- Gesturing/Spontaneous Movement: bringing awareness to spontaneous gestures/movements that are self-soothing
- Help Now!: strategies to get back to the resilient zone
- Shift and Stay: shifting to a wellness skill and focusing on sensations of well-being
- Titration: graduated exposure to sensations of distress
- Pendulation: alternating between traumatic and resource sensations
- Completion of Survival Responses: Inviting the client to complete blocked responses
Working with Clients’ Trauma
When a client is pressed to remember a traumatic event, instead of resolving the experience, it may actually reinforce the fear and stress that are part of the recollection. Scientists have discovered the very act of remembering changes the structure of the memory. Similarly, when clients recount the narrative of their trauma, it can be re-traumatizing.
“It is an individual’s perception of an event as threatening coupled with helplessness that affects the nervous system.”
The beauty of TRM is that no narrative is needed; the body holds the story that words may be unable to express. A new narrative can emerge by processing through sensations in the body.
TRM uses an invitational model and language such as, “I invite you…” and “…or not”, always giving a client freedom and choices. We try to let the client be in charge of the session, since often power was taken away by the client’s trauma. TRM lets the client be the interpreter of his or her own experience.
A Model of Hope
Reflecting back on the TRM training, it became evident that this had not only been a practical, insightful workshop, but also a healing experience. Never before had I attended a professional workshop where there was such a sense of camaraderie, oneness, connection, and shared understanding. Thirty of us, all in the helping field in one way or another: a social worker aiding the homeless in Venice Beach, a clinician doing play therapy with children experiencing the effects of high-conflict divorces, therapists with private practices in the heart of Beverly Hills. One woman in particular stood out in particular, a documentary filmmaker who explores the connection of humans in different cultures. She came to the training to learn skills to help the residents of the impoverished countries she visits.
It was invigorating to share three days with these inspiring people, who were willing to be raw, vulnerable and open to doing their own work. Through our processing and learning of TRM together, we left instilled with the message that, “Adversity is not destiny.” The model tells us that there is only good news! We all have the ability to regulate ourselves and to track our own nervous systems. TRM de-pathologizes the human experience and shows us it is more biological and therefore more in our control, helping us recognize our own sensations of distress versus symptoms of well-being.
It’s all about going with the nervous system and not against it, as well as working with emotions in a different way.
“We do not have to be trapped by the storms of our bodies.”
All quotes and material taken from Elaine Miller-Karas, LCSW and The Trauma Resource Institute’s Trauma Resiliency Model Level 1 Manual (TRI, Claremont, CA, 2012).
“Honesty is reached through the doorway of grief and loss. Where we cannot go in our mind, our memory, or our body is where we cannot be straight with another, with the world, or with our self. The fear of loss, in one form or another, is the motivator behind all conscious and unconscious dishonesties: all of us are afraid of loss, in all its forms; all of us, at times, are haunted or overwhelmed by the possibility of this.”
(Whyte, D. 2015. Consolations. Many Rivers Press, Langley, Washington).
I attended an AA meeting last Sunday morning where the subject of the meeting was honesty. Interesting questions were posed such as:
- “What is honesty?”
- “Did you have a time in your life when honesty was completely disregarded?”
- “As your disease progressed, did it become more and more difficult to tell the truth?”
- “Did you even remember what the truth was?”
- “Did you cheat and steal to get drugs, alcohol, or food for your disease?”
- “Did people in your family lie?”
Lack of honesty certainly goes hand-in-hand with addiction to drugs or alcohol. Substance abusers lie to protect their drinking or drug behaviors, which become more important to them than their relationships with family and friends. The very same lack of honesty is present for most people with eating disorders. Many people lie about their eating habits. “I ate!” “I ate what was on my meal plan.” “I only ate a salad today. Why am I not losing weight?” They may lie when they talk about purging! Or binging. When someone begins to lie in one area of their life, it tends to spreads to many other areas.
When your life has been sustained by lies, it’s hard to open up and let other people see who you really are. But it’s only through living honestly than you can strengthen relationships, conquer problems, build self-esteem and create a richer and more meaningful life.
You may have already seen the ads for Vyvanse, the new FDA-approved drug for the treatment of binge eating disorder. Vyvanse was originally marketed for the treatment of ADHD, but Shire Pharmaceuticals, the drug’s manufacturer, is now promoting it as “an effective option to help curb episodes of binge eating.”
Binge eating disorder (BED) is the most widespread of all eating disorders and affects 1% to 5% of Americans. For years it was classified as a medical condition. But in 2013 the authors of DSM-V saw the light and classified BED as an eating disorder.
Psychological variables such as low self-esteem, depression and anxiety can trigger BED. Genetic predisposition, a close relative with an eating disorder or drug addiction or the metabolic disturbances caused from chronic dieting can also be contributing factors.
When people have BED, they frequently act impulsively. They feel ineffective and alienated and may be haunted by perfectionism. Individuals with BED are at higher risk of developing other illnesses, including anxiety disorder, cardiovascular symptoms, chronic fatigue, depression, infectious diseases and insomnia.
In today’s world of big pharma, it seems like there’s a pill for every illness. Clients who suffer from depression or anxiety seasoned with PTSD and substance abuse often arrive at Mirasol with a suitcase full of medications. But at Mirasol, we believe in “skills, not pills”. In 16 years of treating binge eating disorders and co-occurring conditions, we have found that a combination of cognitive behavioral therapy, dialectical behavioral therapy, nutrition counseling and alternative therapies such as EEG neurofeedback is far more effective than psychotropic medications.
Time will tell whether Vyvanse lives up to the manufacturer’s claims. It’s worth noting that in 2014, Shire paid more than $50 million to settle a claims that it had engaged in illegal marketing tactics, including marketing Vyvanse for unapproved, off-label uses and falsely representing its safety.
A recent article in the February 28, 2015, edition of the Arizona Daily Star calls much-needed attention to the high incidence of eating disorders among southern Arizona teens. Arizona ranks second in the United States for teens who have purged as a method of weight control and has twice the incidence than the U.S. average, according to a recent study by the U.S. Centers for Disease Control and Prevention.
However, I must take issue with two of the article’s conclusions. Firstly, the article attributes the prevalence of eating disorders to Tucson’s climate. It quotes Dr. Nia Sipp, medical director for Sierra Tucson’s eating disorders program, as saying, “Arizona has a lot of sunny, warm days and summer clothing is more revealing, which leads to more body image issues.”
Perhaps Dr. Sipp’s remarks were taken out of context. Although pressure to conform to cultural standards in body size complicates the challenges of acknowledging and recovering from eating disorders, body image alone is not responsible for their development. Eating disorders are a response to a complex set of factors, including genetic, neurobiological, social, developmental and relational. They are often associated with other mental health conditions, such as depression, anxiety, and substance use, and may be linked to bullying and childhood trauma.
Secondly, the article claims that it is very difficult to find treatment for eating disorders in Arizona. Again quoting Dr. Sipp, “Young people can’t find anyone to work with in the Tucson community,” she said. “You can throw a stone and hit an AA group, but there are really no free eating disorder support groups.”
Founded in 1991 and fully-accredited by Arizona Department of Health Services Office of Behavioral Health and the Commission on Accreditation of Rehabilitation Facilities (CARF), Mirasol Eating Disorder Recovery Centers offers residential and intensive outpatient treatment to both girls and boys ages 12 to 18, providing effective treatment to both adolescents and their families.
For teens, friends and family members concerned about eating disorders, the Mirasol website www.mirasol.net offers a wealth of information and an assessment that may shed light on symptoms and their severity. Additionally, Mirasol sponsors a weekly free community meeting for anyone who is struggling at our outpatient facility.
In light of compelling statistical trends, it is important to remember that eating disorders are the leading cause of death from any mental disorder, affecting males as well as females. Eating disorders contribute to serious medical complications across the life span. There is hope, however. Recovery is possible with ongoing support and high quality, evidence-based treatment.
Diane Ryan, MA, CPT
Executive Director, Mirasol Eating Disorder Recovery Centers
In 2000, researchers identified genetic susceptibility for anorexia and bulimia, binge eating disorder and obesity as well as for substance abuse, anxiety, and major depression. Family and twin studies have shown that relatives of someone with an eating disorder are at increased risk for developing a disorder because of a genetic component present in all eating disorders. Studies have shown that 58% – 76% of the incidences of anorexia may be due to genetic factors.
An upcoming issue of the International Journal of Eating Disorders will publish ground-breaking new research by Dr. Howard Steiger that is likely to change our view of anorexia nervosa and its origins. The current project used genetic information from 1,200 anorexia patients and nearly 2,000 non-anorexic controls.
In the new report, researchers found that the longer people suffer from anorexia, the higher the likelihood of alterations in their DNA, specifically in DNA methylation, which can cause changes in an individual’s physiological and emotional make-up.
Dr. Steiger says the study demonstrates a relationship between anorexia and alterations of methylation levels in genes having to do with anxiety, social behavior, various brain functions, and the function of different organs. When gene expression is altered, the expression of traits that are controlled by those genes is also changed. Steiger states that we may come to the conclusion that eating disorders are not just about body image or bad parenting.
“These findings help clarify the point that eating disorders are not about superficial body image concerns or the result of bad parenting,” says Steiger. “They represent real biological effects of environmental impacts in affected people. Here we have physical mechanisms acting upon physiological and nervous system functions throughout the body that may underlie many of the effects of long-term anorexia. The question is, ‘Does remission of AN symptoms coincide with normalization of methylation levels?’”
Every day women are exposed to media of all kinds, movies, TV, magazines and social media that drive home the importance of being thin. But somehow all of these women don’t become anorexic or develop what’s called a “thin-ideal internalization.” Genetic factors may make certain women more susceptible to the pressure to be thin.
In each cell chemical reactions activate and deactivate parts of the genome at strategic times and in specific locations. Epigenetics is the study of these chemical reactions and the factors that influence them. Epigenetics involves genetic control by factors other than an individual’s DNA sequence. DNA methylation is used in some genes to differentiate which gene copy is inherited from the father and which gene copy is inherited from the mother, a phenomenon known as imprinting.
The epigenome dynamically responds to the environment. Stress, diet, behavior, toxins, and other factors regulate gene expression. Many brain functions are accompanied at the cellular level by changes in gene expression. Epigenetic mechanisms such as histone modification and DNA methylation stabilize gene expression, which is important for long-term storage of information.
Not surprisingly, epigenetic changes are also a part of brain diseases such as mental illness and addiction. Understanding the role of epigenetics in brain dysfunction may open the door to being able to influence it. This may lead to the development of new and more effective treatments for brain dysfunctions.
Eating disorders are complex psychiatric disorders in which genes, environment, and gene-environment interactions have a role. The combination of genes and environment can be modified by factors such as malnutrition or stress and this may result in long-term or acute epigenetic modifications.
Genetic variations can contribute to the pathophysiology of eating disorders such as anorexia nervosa or bulimia nervosa. The interplay between genetic and environmental factors is just beginning to be understood. This is the first study reporting alterations of global and gene-specific DNA methylation in a sample of patients with eating disorders.
Steiger’s discovery is important and will lead the way for further research perhaps by learning how to modify epigenetic changes in cells affecting a person’s physiology and nervous system. Will it be possible to prevent more pronounced alterations of methylation levels? When an anorexic patient goes into remission, are changes in methylation levels permanent or will they coincide with recovery? Can we develop medications that will affect methylation levels?
The possibilities for healing the human genome are endless.
Freiling, H., Gozner, A., Romer, K., Lenz, B., Bonsch, D., Wilhelm, J., Hillenmacher, T., de Zwaan, M., Kornhuber, J., and Bleich, S. (2007) Global DNA hypomethylation and DNA hypermethylation of the alpha synuclein promoter in females with anorexia nervosa. In Molecular Psychiatry, 12, 229-230.
Frieling, H., Romer, K., Scholz, S., Mittlebach, F., Wilhelm, J., De Zwann, M., Jacoby, G., Kornhuber, J., Hillemacher, T., and Bleich, S. (2009). Epigenetic dysregulation of dopaminergic genes in eating disorders. In International Journal of Eating Disorders, 7, 577-583.
Pjetri, E., et al. (2012). Quantitative promoter DNA methylation analysis of four candidate genes in anorexia nervosa: A pilot study, Journal of Psychiatric Research, http://dx.doi.org.1016/j.jpsychires.2012.10.007.
Pjetri, E., Schmidt, U., Kas, M., and Campbell, I. (2012). Epigenetics and eating disorders. In Current Opinion in Clinical Nutrition and Metabolic Care, 15 (4), 330-335.
Eating Disorder Hope Award
- Trauma Resiliency Model: A Portal to Healing April 13, 2015
- Honesty March 24, 2015
- Skills, Not Pills to Treat Binge Eating Disorder March 18, 2015
- Are Arizona teen eating disorders caused by climate? March 10, 2015
- Ground-Breaking New Research on the Genetic Origins of Anorexia Nervosa March 4, 2015
- Gone Wild: Backpacking with Mirasol March 2, 2015
- Curing the “Winter Blues” March 2, 2015
- TRE (Tension + Trauma Releasing Exercises) February 23, 2015
- Eating Six Times a Day? February 16, 2015
- Turning Points February 11, 2015
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