Telehealth
Since COVID, many providers have moved to telehealth as more clients are preferring the convenience of this. Research has shown it is equally as effective as face to face. Key benefits are being able to more easily fit appointments into a busy schedule, saving travel and parking time, as well as the cost. Usually the main benefit is still being able to have a session in a space that feel most comfortable, and having comforts on hand, particularly if even getting out of the home is a challenge.
Sessions are provided via secure video link. You will have your own individual link, which remains the same through your treatment. Phone sessions can be facilitated if this is not an option for you.
Considerations when using any telehealth, would be to have a private space in your home, or office (yes, some clients use meeting rooms at their workplace). If this is difficult, some clients like to drive to somewhere where they have a great view and link in from there.
Workers Compensation
Just like public liability insurance, most employers are required to have workers compensation insurance. If an employee is injured at work, a claim is made with the insurer to cover the cost of treating the injury, to assist the employee to return to work. If you are claiming or receiving workers’ compensation, the case manager you are working with is from the insurance company that the employer uses. In some government agencies, wellbeing or liaison staff may also be involved.
Both physical and psychological injuries are covered by the insurance and the employee may have either or both. This is generally determined by the treating GP.
To access workers’ compensation, initially a GP will determine that if injury is work related, then the employee lodges this medical certificate with either the employer or directly to the insurance company. The GP will also make referrals to the specialists for any necessary treatment of the injury. The GP is the central coordinator of the employee’s recovery.
When a claim has been made for psychological support, the insurer must initially approve an initial assessment or treatment before it can go ahead. This approval needs to be obtained from the insurer before seeing the psychologist for the first time. The number of approved sessions varies between insurers. They may approved one, three or eight sessions initially. Once completed, additional sessions can be applied for (max 8 at a time) can be applied for. In session, the psychologist will complete an AHRR (Allied Health Recovery Request), which outlines the diagnosis, assessment/presentation, capacity at the time of the plan and therapy goals. The psychologist lodges this with the insurer, then once approved, treatment can continue. This process is repeated after each block of approved sessions is used, until treatment is finished.
Periodically the insurer may request a report from the psychologist to provide additional information on the employee’s progress in treatment.
Treatment frequency is up to the employee and psychologist, and based on how to best meet the treatment goals. The goals of the treatment can range from resolving traumatic events, improving mood, reducing anxiety or even working through how the workplace injury is impacting on other parts of the employee’s life.
CTP Insurance
All cars registered in NSW require CTP (Comprehensive Third Party) Insurance, also known as a green slip. This insurance is required, so that if anyone is injured in a car accident, the cost of their recovery is covered.
Referrals through CTP are initiated through a GP who will make referrals to relevant specialists to treat any physical or psychological injury. The medical certificate also needs to be lodged with the insurer.
Treatment approval follows the path as workers compensation, as outlined above.
Similarly, treatment in relation to a motor vehicle accident may vary from working through the direct trauma, low mood, anxiety through to how the injury is impacting on other parts of the client’s life.
PTSD and CPTSD
Post traumatic stress disorder (PTSD) is where a person experiences an isolated life threatening or horrific event or situation, such as a serious accident, sexual assault, natural disaster or combat. They then go on to experience symptoms in three main categories.
Re-experiencing the trauma, such as nightmares, flashbacks, intrusive images, being overwhelmed by feelings and thoughts about the trauma.
Avoidance of reminders that might trigger re-experiencing the event, such as people, places, activities or conversations.
Feeling like the threat is still current, such as being very jumpy, hypervigilant, fearful the incident might happen again, which may also lead to behaviours to protect from the incident happening again.
It is generally formally diagnosed if the symptoms interfere with important areas of functioning, such as personal, work, social or educational life.
Complex post traumatic stress disorder (CPTSD) is where a person experiences a life threatening or horrific event or traumatic situation/s which are prolonged or repetitive, where they feel little or no chance of escape. This may range from repeated childhood sexual or physical abuse, prolonged domestic violence or other forms of organised violence. As a result they experience PTSD symptoms with additional complexity.
The experienced symptoms are in the three main categories as PTSD . In addition to this, they struggle to manage their emotions. They may experience emotional outbursts, dissociate or have emotional numbing. They have persistent beliefs of worthlessness, intense feelings of guilt and shame about the trauma. They also have difficulty maintaining relationships, either engaging in or remaining in them.
Again, a diagnosis would also require the symptoms to interfere with important areas of functioning, such as personal, work, social or educational life.
Phases of EMDR
EMDR is based on eight phases to ensure the most comprehensive reprocessing.
Phase one – History and treatment planning Initially a timeline related to trauma experiences is developed, which enables a greater understanding of which events are the best to target and the order. This phase also includes screening and assessment for dissociation, to address this before processing, so it can be done safely. This phase also clarifies the treatment goals.
Phase two – Resourcing The focus of this phase is to ensure stability, which assists with smoother and more complete processing. It would include self regulation strategies such as ‘peaceful place’ (imagery) and any parts work needed to manage dissociation.
Phase one and two will vary in length depending on the complexity of traumas and the degree of stabilisation needed to safely reprocess memories.
Phase three – Assessment This phase identifies the specific memory to be processed first/next, also known as the target memory. It then identifies the other key elements, such as the associated negative belief, the adaptive belief, emotion and body sensations related to the target. At this point the baseline measures of the target are also set, specifically, how true does the adaptive belief feel, and how distressing the target memory currently is.
Phase four – Desensitisation This is the most well known phase of EMDR. In this phase the client focusses on the target memory and is simultaneously provided bilateral stimulation which could be eye movements, audio, tapping or a combination of these. The bilateral stimulation may be rapid, if needed to assist in the desensitisation. This is done in short bursts with regular check-ins on any change. During this phase, thoughts, feelings and body sensations may emerge or change. This is repeated until the target memory has a zero (or one if relevant) level of distress.
Phase five – Installation Within this phase the memory as it now appears is paired with the adaptive belief and slow eye movements are used to strengthen the felt sense of the belief with the memory. This is installed until there is a felt sense that it is true, measured with a seven (or six if relevant).
Phase six – Body scan This phase has the client scan their body for any resistance to the adaptive belief in the context of the target memory. If there is any resistance, this is processed further until the scan is clear.
Phase seven – Closure This is about regrouping to the here and now and debriefing in relation to the processing. If the target memory was not fully processed, then tools such as ‘containers’ are used, so the memory can be further processed at a later date. Other tools may be used to ensure clients are in a state of calm before finishing the session.
Phase eight – Evaluation This phase is done at the next session to review and check the target memory is still desensitised and the adaptive belief still feels true. The next target memory or another aspect of the target memory can then be planned.
While the eight phases are distinct and have different functions, phase one and two can often be done simultaneously rather than sequentially, to maximise stabilisation.
In terms of working through trauma memories, some target memories may require additional processing sessions to reprocess different elements of the memory, such as multiple negative beliefs.
Types of EMDR
The eight phases of EMDR can be facilitated in more than one format. Where there is a known or identified trauma, particularly if it is an isolated incident, Standard protocol is usually used, which is described above.
Where a specific incident is difficult to determine, as the first occasion may have occurred when quite young, attachment informed EMDR may be used. In this process, the eight phases are still used, however the issue is ‘bridged’ back to the earliest memory for processing.
Within both processes the eight phases are still utilised, however the target memories are accessed in a different way.
Regardless of which format is used, there may be multiple processing sessions needed to address the various emotions and negative beliefs that relate to a specific trauma, which are likely to still be playing out in the current day.
Parts work
Parts work is a modality sometimes used to assist in therapy. Models range from inner child to Schema therapy modes to Internal Family Systems. At times they can greatly assist as a stand alone modality or in conjunction with EMDR.
Consider the last time you may have felt ‘torn’ about something. A part of you wanted to do something but another part might have been cautious or scared. These could be described as “parts”, where listening and negotiating between parts could help resolve the inner conflict.
Another situation to consider is where a part is ‘triggered’ and we react with hostility, sarcasm or even panic. This could be seen as a vulnerable part (child or adult) being activated and another part coming in to protect them. Through parts work, by resolving the trauma of the vulnerable part, the protector no longer needs to react, in turn we do not react with hostility, sarcasm or panic.
This modality is particularly valuable when working with dissociation or where there are blocks in EMDR processing.
Self care and stabilisation
Self care comes up in all forms of therapy. These strategies can include:
- having a consistent routine in the day and for sleep
- eating well
- trying to get any exercise possible
- healthy contact with others
- self-compassion, self-understanding
The focus of self care is to assist in stabilisation and the development of strategies to enable emotional regulation. This is foundational and therapy then builds on healing, rather than focussing on crisis management.
Stabilisation is about being able to stay in the ‘window of tolerance’ or bringing our self back to the window of tolerance. This window is the state were we are able to manage stress and think through decisions. When out of this window, the stress response is activated and we go into either fight/flight, or freeze/shutdown response.
These responses are very normal and healthy when reacting to an actual threat. However if overactive to any possible perceived threat due to trauma history, it can create day to day difficulties.
Relaxation strategies are used to reduce anxiety and/or the fight/flight response. This can range from mindful breathing or visualisations through to yoga. Through the regular practice of relaxation strategies, muscle memory is developed. In turn when the stress response is activated, there is a greater capacity to return to the window of tolerance and manage the situation more effectively.
Where the freeze/shutdown response is activated, it is common to develop strategies in grounding. These can range from using tactile objects to naming things in the room. The function of this is the same, to return to the window of tolerance.
Parts work can also be used as part of stabilisation strategies.