We'll get started. Good afternoon, everyone. I'm Dr. David Stifler on behalf of the American Academy of Addiction Psychiatry. Welcome to today's webinar, which is the fourth in our monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. This is hosted in partnership with the Oregon Health and Science University and New York University. We're excited you could join us today and offer you these live trainings that will be held the second Wednesday of each month from 5.30 to 7 PM Eastern time. We'll be taking a break in December and our next presentation will be Wednesday, January 11th, and at that time, Dr. Keith Humphreys will be presenting on 12-step facilitation. Please check the AAAP website for updates on other upcoming speakers and topics. A few housekeeping items before we begin the session. Please feel free to ask questions anytime during the presentation by clicking the ''Questions'' button in the lower portion of your control panel and typing in your question. We will reserve 10-15 minutes at the end of the presentation for Q&A, and we might allow you at that time to actually ask the question yourself. You can also contribute to the chat box during the talk for ongoing discussion if you would like. Additionally, in the chat box, we will put instructions regarding how to access the handout for this talk. Finally, after this session, you can claim credit by logging into your AAAP account in OASIS to access this course. Please complete the evaluation and follow the prompts that are provided to claim credit. Hello, I'm Chris Blazes from OHSU, and we're very excited today to have a true pioneer in our field with us, Dr. Lisa Najibitz, and she's the Director of the Treatment Innovations and Adjunct Professor at the University of Massachusetts Medical School. She was on the faculty at Harvard Medical School for 25 years, and a Research Psychologist at the Veterans Affairs in Boston for 12 years. Her major areas of work are addiction, trauma, development of new treatment models such as seeking safety, which we're talking about today, of which I'm sure everyone here knows she created, as well as clinical trials research. She's the author of over 200 professional publications and various books. Her awards include the Betty Ford Award for the Addiction Medical Education Research Association, the Young Professional Award for International Society for Traumatic Stress Studies, the Early Career Contribution Award for the Society of Psychotherapy Research, and the Emerging Leadership Award of the American Psychological Association Committee on Women. She was the President of the Society of Addiction Psychology of the American Psychological Association and continues to serve on various advisory boards. She's also a practicing clinical psychologist and supervisor. Once again, thank you, Dr. Najibitz for joining us. My sincere pleasure. I am really delighted to be here and be part of what sounds like a wonderful training program. I'll be covering today two models that are designed for addiction and or trauma. Those words and or are very important because the models can be used, certainly for co-occurring conditions. That was the origin for seeking safety to begin with. But in years since, it has been broadened out to be used with people who might have just one or just the other. The other model we'll be talking about today is called Finding Your Best Self, which is a more recent model published in 2019. We'll be going into a menu of what both of these models are and also what is their usage. The perspective that I really come from with both of these is really a public health orientation. We know that most people who have trauma and or addiction may not end up in professional care. We know that many of them will end up in programs that are under-resourced and overwhelmed. The idea with these models is trying to make them as low bar as possible. Low obstacle to entry and able to be delivered by anybody. Just by way of disclosures, I'm the Director of Treatment Innovations, which provides resources such as training and materials related to models that I've developed, including Seeking Safety and Finding Your Best Self. Also the author of those books, as well as some other books, including a Woman's Addiction Workbook and receive royalties for those. One thing I always like to preface as we dive in is, I truly am not looking to sell books or sell anything. I think we live in an era where there is so much being sold. What I would say is, as we go through today's talk, keep in mind that the principles, whether or not you ultimately do Seeking Safety or Finding Your Best Self, the principles relate to how to improve care and sensitivity for people with these issues, trauma and addiction, regardless of what model you end up implementing. There are certainly other models out there in the field. When we go to the Q&A segment, you're welcome to ask questions about other models as well. We'll be going into a brief overview of the two models, how they're relevant to patients and providers. As we said, indications for each model and differences between them as well. I'll focus heavily on implementation aspects, because really that's where the rubber meets the road as they say, what does it look like in practice? With real regard for linkages between trauma and addiction. As we said, people don't have to have both. If they're participating in one of these models. However, the linkages still are very important because there has been wonderful recognition over these past several decades that trauma and addiction go together. Sadly, they are twins. People reach out for addictive behaviors when they're in the aftermath of trauma. Addiction sets people up for trauma due to the vulnerabilities related to addiction. In some places, people grow up in families or communities where both are present from very early on. Certainly, those linkages are very important. We'll talk about helping the patients directly, but also helping their families and helping those in their orbit. Because often those are the first people to recognize the kinds of issues the patient may be struggling with. As a backdrop, public health, as we said, is the framework and focusing on increasing quality of care and access to care. As we said, these are learning objectives. I won't repeat them. We've talked about them basically linkages, interventions, meaning seeking safety and finding your best self. Usage of each model and adaptation. And we will focus on how to adapt based on setting, provider and all the different client factors that can impact care. So both of the models really developed for adaptation because we know that patients do come in through so many different pathways, whether that's a specialty program for addiction or mental health, into a private practitioner's office, in through corrections or a homelessness program or primary care. So whatever the setting may be, the goal is to meet the needs where they are. So first, I'd like to quote here from Edward Kansian, who really developed the term self-medication back in the 1980s, which since has become a very important concept in the field. So he said, quoting from his book with Mark Albanese from 2008, fortunately or unfortunately, the suffering and symptoms of PTSD temporarily yield to the effects of substance abuse, and thus they run the risk of becoming addicted. And that's the pathway of trauma leading to addiction. And what's especially important, I think, in this quote is the term fortunately or unfortunately. Certainly, we know the unfortunate version of this. People who reach out for a substance when they're in distress from trauma and end up becoming addicted. That is the classic self-medication pathway. Fortunately, is a much more subtle point. And it's the idea that it actually may have saved their life to reach out for some sort of addictive behavior, whether that's substances or any of the behavioral addictions, gambling, eating, working, exercise, pornography, etc. So sometimes some of those addictive behaviors actually buy them time to stay alive so that they can just survive and hopefully get into treatment or get some support or care for what they're struggling with. So always taking the approach, trying to understand from clients directly, why were they using? What did it serve? What were the functions? The second quote is the opposite. Addiction leads to trauma. The addiction lifestyle contributes to an ongoing pattern of trauma. And that may be hanging out with people who end up harming them, sexual assault in the context of intoxication, crime related to addiction that puts them into physical harm, and on and on. And finally, the pathway where each impacts the other. Childhood trauma, the quote goes, can cause persistent dysregulation of the body's stress response systems. A vicious cycle is set up as the substance used further dysregulates the stress systems. And we observe out of control behavior. Basically, speaking to the neurobiology of trauma and addiction and also the idea of this vicious cycle, sometimes called a downward spiral. Each of them, trauma and addiction makes the other worse. And so by the time we see these patients in treatment, sometimes they have fallen very far down. And the goal is, of course, to help lift that up. I'll just mention some of my favorite free resources that you can easily Google and find. One of them is the treatment improvement protocol called TIP, T-I-P, Treatment Improvement Protocol Number 57 from SAMHSA, the Substance Abuse Mental Health Services Administration, called Trauma Informed Care and Behavioral Health Settings. And if you just search online for TIP, you'll find a lot of great resources. And if you just search online using that phrase, TIP 57, you will find it. It's a free download and it provides a wealth of material for frontline providers in any setting to be able to become more aware of trauma informed care in all kinds of ways. And it's a great training tool for use in your program, internal workshops, peer support work. Any way that you can try to go through that TIP is wonderful. A second called Rethinking Drinking. This is from the National Institute on Alcohol and Alcoholism, NIAAA. And if you just research the phrase Rethinking Drinking, I think it's one of the best publicly accessible websites that's really designed for patients themselves to identify, do they have a problem? And finally, the third one, National Child Traumatic Stress Network is about families, children, adolescents struggling with trauma. And the NCTSN, you can see the website there, is a collaboration between academia and government to create resources for this particular population. So now moving on to seeking safety and finding your best self. Seeking safety was designed for providers and providers has become very expanded over time in terms of what that means. I'm happy to say there was a very large clinical trial just a few years ago by my colleague Annette Crisanti in New Mexico, who did a study showing that it works just as well with care support workers as it does with professionals. So there is evidence base for its delivery by peers. And certainly by any provider in the setting, any type of professional, it can be paraprofessionals. The model doesn't require any particular training, experience, background, certification or licensure. The only exception is if someone is doing a research study that's going to have publishable outcomes or publicly available outcomes, in which case we do the usual thing and require the typical clinical trials. Parameters such as fidelity and training, but for regular clinical implementation. In keeping with the public health health focus, it really was designed to be able to be used by anyone. And it's evidence based. There are over 65 publications representing a wide variety of pilots, randomized and controlled trials, multi site trials and adoption studies and implementation studies and so on. And the website Seeking Safety. Which is SeekingSafety.org, or if you just Google Seeking Safety, you'll get to it, has freely downloadable articles from the evidence base. So if you click on evidence, you'll see there it has a very long list of these studies, low cost. The only thing needed is each provider has to have one book that they can use forever more with their own clients. And that's it. It includes handouts that they can share, whether by telehealth or hard copy. And the idea is to really sort of allow them to move within the 25 treatment topics in whatever ways work for them. It does not have to be 25 sessions. That's why they're called topics and not sessions, because they can be done over whatever time length is available. So some people will do just a few topics if they're in, for example, in a rehab or detox setting where people may be there only for a couple of days. Great. Just do a couple of topics or maybe there's a long term residential program where people are going to be there for six months. Great. Take a topic and do it over several sessions. Really deepen the work. So it's basically 25 options, each one representing a safe coping skill that applies to both trauma and addiction. And we'll talk more about those in a moment. Finding your best self really speaks to something I have long wanted to do, which was to write a book that could be used to self-help, but also could be used by others in the patient's orbit. So it's a model that basically can be done as self-help. It can be done professionally delivered. It has a chapter on how to do it in a professional context, meaning just providing some guidance on a structure to the session and so on. There's a whole lengthy chapter for family, friends, partners, sponsors, anyone else who's trying to provide support for that patient and how to interact with them, how to make use of the materials and resources for them as well. It draws on evidence based methods. At this point, it does not have an evidence base in and of itself. We have not done a study on it, but it very much draws on established methods. It is a lower cost than seeking safety. I'll just say both of these books are published by Guilford Press, who owns the copyright to these. So they're the ones who set the parameters on how it's distributed and cost and all that stuff. But the nice thing with this book is it is very low cost and it has 35 short chapters because it was designed to be sort of digested in these ways that are sort of bite sized that anyone could help the patient with. And we'll talk more about, of course, what those look like as well. What they have in common is they are striving to be highly compassionate and engaging. We certainly know that for many patients, they may have already been through systems of care. There's that revolving door concept. They've been through a lot of treatment. And yet here they are again needing help. And so trying to make the material as engaging as possible to speak to the heart so that they will feel like we're getting their experience of how devastating these issues are and also making it lively enough to sort of draw in their attention. And I'll just say for providers as well, really important to, I think, have materials that feel like it fits with your best clinical judgment that gives you flexibility. First and foremost, I went into the field as a therapist or counselor, and it really matters to me to feel when I'm reading material to feel respected that my judgment, what I know about my clientele is going to matter. So these are not they're structured models, but they're not strict models. Both of them are integrated, meaning that when we're dealing with co-occurring disorders, we deal with both at the same time throughout. And this really has been one of the biggest revolutions in the field, starting back in, I would say, the 80s, early 90s, the development of attention to co-occurring disorders. And there now has been work in so many different aspects on that. Many, many different models for different types of co-occurring conditions. But here we're focusing on trauma and addiction. And I'll just mention, if you are looking for further information, the website here for seeking safety, for finding your best self and two other models that are available. Each one is, again, distinct from the others. A woman's path to recovery is basically a gender focused model based on a woman's addiction workbook published in 2002 and creating changes coming out in 2023, which is a. New model that I'm that is just being sent off to the publisher now, and it's where seeking safety focuses on safe coping skills, creating change, focuses on moving into the narrative about the past, moving into some of those more intense kinds of details. So the stages of recovery is a really important piece of background for understanding where seeking safety comes from. And Judith Herman, the psychiatrist who has been absolutely pivotal in the field of trauma, published a book in 1992 called Trauma and Recovery. And if you haven't read that, it is very worth reading. It is eloquently written and it's now a classic in the field. And she identified what were called stages of recovery, meaning how does a person get over trauma? And she identified three core types of work, the first being safety, meaning education about trauma, about post-traumatic stress disorder known as PTSD. Coping skills, how do you help the person establish stabilization, learn how to decrease intense reactivity that goes with trauma, learn how to get out of unsafe relationships and unsafe behaviors and unsafe situations to the extent you can help the person get out of those. Stop misusing substances or other addictive behavior if they're doing that. Basically building a foundation of being able to function in the world. Having done that work, the idea was the person could then go on and do what she called the second stage, mourning and remembrance, which we now call by many different names. There are various models for this stage two. Prolonged exposure is one of them, EMDR. Eye movement desensitization. Reprocessing is another one. Cognitive processing therapy, narrative exposure therapy, written exposure therapy. There are many different versions, but the essence of all of them is having the person walk into the details of what happened and process it, move through it, feel the feelings, explore the memories and work it through so it no longer holds that kind of emotional power over them. And finally, stage three, reconnection, establishing good work, social life, and sometimes becoming a healer to others as well. We now don't think of it so much as stages that people have to go through in sequence or even do all of them. Now they're thought of really as different types of work. And so some people may spend their whole lives just working on safety. They may not want to move into telling their story, the stage two work, or vice versa. Some people may be functioning pretty well, but they really need a place to talk about what happened. And they may just move right into doing that sort of more detailed narrative kind of work. The bottom line is they are qualitatively different and different patients and different providers may need different kinds of training for these. In general, the idea is safety-based methods, at least with seeking safety, as we said, does not require training, anyone can do it. The stage two models, mourning and remembrance or exposure-based work, uniformly, people say those have to get training, typically supervision, certification, and so on, because they're much more intense emotionally and one wants to make sure there's no re-traumatization of people. So seeking safety basically focuses on that first piece of work, safety, just how do you do that? And the model arose back in the early 1990s. I applied for a grant from the National Institute on Drug Abuse to develop a model for co-occurring PTSD and substance use disorder. And it struck me that, you know, certainly what had been said for a long time at that point was people with substance use disorder should not be telling their trauma story and moving into PTSD work, because that's way too intense. They're going to increase their substance use. They're going to become suicidal and so on. And there was wonderful documentation showing that those iatrogenic effects did actually occur. This wasn't coming from nowhere. It was actually a very wise choice. But the idea was that if you keep telling people what had been said for a long time, and sometimes one still hears, if you tell patients, gee, I get that trauma's important to you, but we can't work on that until after you've been sober for a year or longer, you end up undercutting the ability to engage them and move them into work that's meaningful to them. Studies have shown, for example, that if people have both PTSD and substance use disorder, they typically more want treatment for the PTSD than they do for the substance use disorder. And that certainly fits what we understand, that people basically often don't recognize the substance use disorder. So long story short, seeking safety, I conceptualize it as a way that from the start of treatment, they could work on both. And the way to make that safe was to focus only in the present and on coping skills so that we specifically and explicitly say, we are not moving into that past narrative, which may be way too overwhelming for the person. So in seeking safety, we're focusing on general stabilization, and it has been used extensively for the kinds of complex and vulnerable populations that have been excluded from the vast majority of PTSD treatment trials, meaning people who are homeless, who have current domestic violence issues, currently involved in the correctional system, have cognitive impairment, have multiple stressors, poverty, discrimination, job loss. People who are complex and vulnerable in those ways are generally considered not amenable at that point to doing that more stage two kind of work. So seeking safety has been used with these populations routinely. And I'm very happy to say what the evidence shows is that the adoption of it with them, the satisfaction with them, the outcomes with them have been very positive. It's also been used extensively with non-English speaking translated into 15 languages and with highly diverse clients, highly diverse based on ethnicity, based on age. It's used with adolescents through adults of all ages. Highly diverse in terms of gender, across genders, in terms of trauma types. It's been used with veterans, with military trauma, it's been in military sexual trauma. It's been used with people with childhood-based trauma and all the many different types of trauma. And similarly with all types of addictions, all types of substances. And the evidence base is strongest certainly on substance use disorder. There's a recent trial we just completed on gambling disorder that also had positive outcomes. So there are quite a lot of published empirical articles as we mentioned across a wide variety of settings. And typically these samples have been chronic and severe. Basically both disorders, PTSD and substance use disorder for many, many years. And there was a government analysis that I think is quite interesting showing that it has an 88% likelihood of benefit relative to cost. The citation is at the bottom and you can also find it on our website. If you click on evidence and summaries of evidence, you'll find you can link to it through there or there's a citation here as well. That seeking safety came in as one of the top three of the 23 substance use disorder models that were analyzed. Higher than these other models, which I say with all appreciation are wonderful models. Motivational interviewing, motivational enhancement therapy, relapse prevention are classic foundational models in the field. And of course there's no one magic bullet. The goal is the more treatment, the better, the more many types of treatments patients can get the better. So what is the content of seeking safety? As we said, there are 25 topics evenly divided between cognitive, behavioral and interpersonal themes plus case management. These are often clients who have intense need for all kinds of treatments. And so that's one of the components of seeking safety, explicitly evaluating that and referring to them, referring them into as much additional care as possible. Designed for flexibility, as we said, it can vary in the number of sessions, modality designed for group or individual. Many programs do it in group because that's certainly cost-effective and the common way that most delivery occurs and especially substance use disorder programs, but it can be done in individual as well. They can be open, they can be closed groups if it is being done in group. Basically, we understand that these clients often have chaotic lifestyles and we welcome them back at any point. If I'm doing it as a group, I typically will just start with topic one and I go through 25 and patients can join at any point, topic five, 10, 20, and then they just keep cycling around and getting as many as they can. Some programs prefer closed groups, that's fine too. As we said, across gender, ages, levels of care, it's been done in pretty much every level of care I can think of. And as we said, provider credentials, the order of content delivery in terms of which happens first, again, is flexible. Dosage, sometimes it's done as an hour once a week, sometimes it's done as an hour and a half, twice a week. Some places, I'll just give you the extremes, primary care, people have done it in little 20 minute segments just before someone was going in to see their PCP. On the other hand, in a jail setting, one program did it every day for two hours because they wanted their patients to get as much of a dose as possible before they left jail within 30 days. So all of that or anything in between. And certainly in terms of who can enter Seeking Safety, it's wide open. The suggestion is let people in and anyone, basically, that is appropriate for your setting. And if you're doing group, appropriate for any group. And then if there's a problem, you can always try to manage that or then shift them out if needed. But we don't have criteria that they have to be at a certain level of severity or a certain level of motivation or a certain level of anything. It's basically take all comers. Most everyone needs help with coping skills. So what does the session look like? It starts with a check-in that's designed to be like a temperature check. How are the patients doing today? And I'll give the example here of group, but it's the exact same format for individual as well. So it's basically five questions designed to just see how they're doing because they have so many different issues that one has to sort of triage what is most important to focus on, but we're trying to get the overview when they first check in. So the check-in is since the last session, how are you feeling? Which is basically an update. How are you doing? What do you want to let us know? What good coping have you done since the last session? Which is designed to reinforce strengths and gains. The third question, any substance use or other unsafe behavior. And unsafe behavior can be anything that's relevant to that patient. So it might be another behavioral addiction, for example, excessive gambling or eating or so on. It might be self-harm. It might be hanging out with people who are unsafe for them. It might be driving too fast. Anything that's relevant to that patient. We're trying to always sensitize them to notice their unsafe behaviors. And those become the primary target of the session. Did you complete your commitment is the next check-in question. And that's just basically homework, which is always optional, but just designed to help them move more quickly and strongly through treatment by doing things outside of sessions. And I'll just mention the commitments can be pretty much anything, as long as it's specific enough to say they did it, yes, no, but it doesn't have to be in writing. Many people feel that they weren't good at school, so we don't require writing. Typical commitments might be, I'll ask my boyfriend not to offer me substances, or I will try this week doing meditation every morning before I interact with my children, so I won't blow up at them, whatever it may be. By the way, we do call it a commitment, not homework, because commitment is just a much more positive-sounding recovery-oriented term. And finally, community resource update, that's part of the case management aspect where throughout treatment, we're trying to give them referrals into care. And basically, here we check up, did they do it? Then there's a quotation that's designed to be inspiring. So the one from, for example, the PTSD topic is from Jesse Jackson, who said, you're not responsible for being down, but you are responsible for getting up. And we talk about what's the main point, and then link it to the topic. It may not be your fault what happened to you, but there's a lot you can do now to get better. So the quotation is just a minute or two, and then we're just designed to emotionally pull them into the topic of the day. And finally, the topic is the main part. That's where we give them the handouts that's focused on one particular safe coping skill, and we'll see those in a moment. And checkout happens at the end, and it's just briefly a couple of questions. Name one thing you got out of the session, if anything. Any problems with the session, we always want to know how they did with it. And what's your commitment? So the session is structured because we want to make use of time. We want to share time. We know clients have so many different needs. We want to focus it in ways that are going to be productive. So what are examples of the topics? PTSD, taking back your power. And by that, we mean being compassionate about your experience. And they are beating themselves up internally about what went wrong or their mistakes or blaming themselves unfairly for trauma. So we give them education about what PTSD is and talk about being compassionate toward it. Substance abuse, working on a way to decrease or eliminate that. And it's open to an abstinence-based model or harm reduction or controlled use based on your philosophy of your program or your practice. The key thing is just having and writing what the plan is so that there are specific parameters. Asking for help, very straightforward. How do you reach out? Detaching from emotional pain called grounding, which is designed to help them have quick go-to strategies, sensory-oriented, to be able to reduce any intense emotion or trigger or impulse. So when they want to reach for a substance, okay, here are strategies you can use. Taking good care of yourself, as it sounds, basically how can they take better care of their body, their environment, which often are so lost as part of trauma and addiction. Setting boundaries in relationships, how to say no to unhealthy relationships and say yes to healthy ones. Creating meaning. What are the core beliefs that they've developed about themselves and about the world and helping them shift into healthier kinds of meanings? The handouts for today give the full list of topics and there are 25 of them. And they're pretty evenly divided between cognitive, behavioral, and interpersonal. And they are all, how can I put it? If a client, for example, does a cognitive topic and doesn't like the cognitive piece so much, you can shift to next time doing an interpersonal one. You don't have to do them in clusters, all doing the cognitive and then all doing the behavioral and so on. It's basically just mix and match based on what your clients need. I'll just name the other ones, compassion, honesty, hoping with triggers, healing from anger, getting others to support your recovery, healthy relationships, integrating the split self, which is about this core mechanism that occurs in the mind during trauma and during addiction, which is splitting different sides of the self that cause unsafe behavior. Red and green flags, signs of spiraling upward or downward and trying to put in place a safety plan, life choices game, which is a review topic, and on and on. Shifting now to finding your best self, which may be less familiar to people. And I'll just mention that there are only two chapters of the 35 in finding your best self, only two overlap at all with seeking safety. And I wanted to embed two of them two of the most popular in the seeking safety model into this finding your best self book. One of them is grounding because it's such a go-to strategy that's so key for people to learn for emotion regulation. And the other is the list of safe coping skills from the topic safety and seeking safety. That's a list of over 80 different safe coping skills. It's kind of a go-to handout that patients can use at any time when they're thinking, I don't know what to do. I don't know how to cope. Take a look at the list. Is there anything on that list that may help you? And they can always typically find something and it also generates a lot of their own creative thinking about other methods that they come up with. So finding your best self aside from those two, everything else is completely different. To give examples, we won't go into all of these, but for example, it's medical. You're not crazy, lazy or bad is basically education about trauma and addiction. How do people change? Looks at core change mechanisms, really respecting that people change differently. Some people change happens primarily interpersonally through the influence of positive role models and treaters and supports and so on. Other people pretty much do it on their own, but they do it through education. Some people it's through negative consequences, many different methods of change, but we talk about it there so that people can just become aware of what helps them to change. Listen to your behavior is kind of the anchor, always going back to the idea they may feel all kinds of things. It may take months or years to feel better. They may still have depression and anxiety and anger and so on, as long as their behavior is safe behavior, is functional behavior, they're on the right path. So we're really trying to reinforce behavior, which typically changes before the feelings change. Social pain, that's an example. What I tried to do in this model is really bring in some topics that I haven't seen addressed in certainly other models for trauma and addiction. And this would be an example of it, that studies show that people experiencing social pain, meaning ostracism, devaluing, being scapegoated and so on, basically causes when people look at neurophysiology studies causes the same kinds of pain responses as physical pain. Social pain is sadly prevalent in trauma and addiction, which are both very highly stigmatized. And here we talk about that. The next one, why trauma and addiction go together is about the link, forgiving yourself, one of the hardest things for patients to do. It often takes years for them to really get to true forgiveness for the trauma, for the addiction. Culture of silence is about silencing that occurs at systemic levels, also within families, within peer groups. It's sort of a sociology, if you will, of silencing and how devastating that can be for people who have gone through trauma or addiction. Motivation, we talk about trying to figure out where they most feel motivated and the idea of leveraging one to help the other. How to survive a relapse, just some strategies. The next set, identity and perception are sort of a pair. Identity being, how do they view themselves? And we certainly know identity gets affected by trauma, by addiction, especially if they're chronic or severe. It changes fundamentally how they view themselves, typically in very negative ways. And so we talk about that explicitly. Perception is the opposite, how other people view them. And that certainly impacts their identity. But talking about it very overtly, how they are seen by others, how they're treated by others, I think is very validating. The chapter format for finding your best self is basically similar to Seeking Safety, not totally identical. But basically, there's a quotation. I love quotations. So each chapter starts out with a quotation. Then key points, because again, this is designed for self-help or any family, friends, sponsor, partner, et cetera, to help work with them on it, or provider. So it basically tries to give as clear and simple language as possible, as brief and concise as possible. So some key points. Every one of the chapters has exercises that they can do. Self-reflections, as I say in the opening to the book, these are the questions I would ask if I were sitting with them here in the room. So it's trying to get them to relate the material back to themselves. And then finally, my favorite part of each chapter is called Recovery Voices. And that's where I was very privileged to have people who themselves were in recovery from trauma and or addiction, who read basically a chapter and then commented on how that chapter related to their own recovery. So it's many different voices, different genders, different types of experiences, different types of addictions, and so on. It's a couple of paragraphs, but I think it's really hearing from them in their own language how the material relates. So I think it's very inspiring. There are some other aspects as well. Appendix A in the book is a very lengthy segment called How Others Can Help, Family, Friends, Partners, Sponsors, Counselors, that talks about the impact on them in working with someone or interacting with someone who has trauma and or addiction and the toll it can take, and how to interact in positive ways. We certainly know that many patients feel the family, for example, often doesn't understand. People may sort of helm them about their addiction but not understand about trauma and so on. So we're trying to really give a compassionate view on it, compassionate both toward the patient and toward these helpers. How to pick a safe helper. Basically, the idea is that the patient can give this chapter to people in their life if they choose to. Or these people can pick up the book and engage the patient with it. Appendix B is resources, just a lot of resources on trauma and addiction. There's so much now that people can benefit from. Appendix C, excessive behavior scale, is basically, I looked far and wide to find a scale that could assess across all the many types of addictions. We certainly know most of them are not defined in the DSM-5. There are very few that are defined there. Substance use disorder and all the variations of it, including alcohol use disorder, gambling disorder, binge eating disorder. Those are the ones that are pretty much the key ones described in DSM-5. But informally, people certainly speak about addictions to many other kinds of behavior. So this scale was developed to try to create sort of one evaluation that could be used to assess across any type of behavior. Now, notice it's called excessive behavior, not addictive behavior, because the word addiction can turn people off. So it's any behavior they feel is excessive. And basically, it just gives a way for them to identify what those behaviors may be. And then it has a series of seven questions they can ask themselves about any of those behaviors that may be problematic. Appendix D, a brief quiz on trauma and addiction. The goal is very much active learning, trying to really just reinforce, are they learning the concepts? I'll just mention that the handouts for today's training include a full chapter and also some brief excerpts. And I can bring that up now for a few minutes so that we can take a look at that. As I do that, I'll just mention that this is one example called See the Link. This is from Finding Your Best Self where we have this exercise, what are the reasons for using a substance or other addictive behavior? And there are certainly many reasons people will give. Oh, I'm drinking alcohol to get to sleep. I'm taking cocaine to feel sexual. I'm doing social media all the time, so I'll be cool and popular and so on. So many different reasons on the left side and then linkage to trauma on the right side. So I'm going to briefly pull up the handout so that you can take a look at basically the, stop the screen share for a moment while I pull this up, and basically looking at the chapter excerpt and then the whole topic. So I'll just mention also that on the Seeking Safety website what you'll find is there are three topics you can fully download that are excerpts from the book. And basically you can try them out with patience. You don't have to have the full book. You can just try them out and see how it goes and then go from there. So now I'll share the screen again and basically show you the handouts. Okay, you should be able to see at this point it says finding your best self, a new model at the top. And you'll see here that it goes through the table of contents, all 35 different chapters and information and resources and things like that. And just to give a feel for it. So this is complete chapter from Finding Your Best Self called Wish Versus Reality. Starting with this quote from Garrison Keillor, the American humorist who said, sometimes you have to look reality in the eye and deny it. And we certainly know that with trauma and addiction, minimization, denial, shame, guilt, really lead people to not own or not express what's really going on. So this entire chapter is all about how to help them face truths about trauma and addiction. So as you can see, it talks about trauma and addiction are perpetuated by not seeing certain truths. And there's a deep wish often to believe things are different than they are. And it can happen in many different ways. Wanting to make it better than it is. I'm fine, he loves me, even though he hits me. Wanting control. Yeah, I can quit any time. I could have saved my money if I had been there during the battle and so on. So many different reasons, wanting to believe, wanting it to disappear, wanting to be normal and so on. So we sort of give them this opening around how there's a normal wish to not believe what's happening is actually happening. And then we talk about the courage that's needed to really look at it and give some examples of what it sounds like. And throughout, we're really trying to normalize these things. So often I think these patients can feel that, you know, why can't I just stop using? Why can't I just get with the program? What's wrong with me? And so we're really trying to validate. It's not easy to do this, but it can be done. And so addiction example here, for example, my liver function test is showing a problem. That would be facing the truth versus not facing the truth. My drinking isn't all that bad. Trauma example, not facing the truth. He isn't as bad as people say. I know he loves me versus facing the truth. I can't excuse his yelling and hitting me anymore. And then we go on what it feels like, you know, really just sort of helping understand. It may feel uncomfortable at first. For example, you may cringe with embarrassment or shame when you see what you've been pushing away. It may feel like the point of despair. There's a feeling of surrender, really just trying to give them the qualitative experience of it. And then this section, questions that help. And certainly as you can see, this isn't something where one could go through all of this in one little, let's say 50 minute session, but it's really opening up things that create a conversation. And then if there's more time, certainly you can do more or do it over multiple sessions. But just trying to help them, typically if I'm doing it, I'll say to the client, okay, is there one of these questions that speak to you that you'd want to try to talk about? So can I own my truth, even if others disagree? What would my higher power say? For example, people who are very engaged in 12-step, I think that's a very meaningful question for them. What feedback am I getting from people who truly care about me? So just different angles on breaking down the defense, if you will. But instead of using, as people may remember, hopefully we don't see this as much anymore at all, but the sort of harsh confrontation models were used historically in addiction treatment to break down denial. And this chapter, if you will, is a gentle approach to breaking down denial. So then it goes from there, to here we have an exercise, the good that can come from facing your truth. And we give them an example. Here's what it sounds like for addiction. Here's it for trauma, very simple questions. And then toward the end, we have an example of recovery voices. Of course, all the names are changed, but this is a client who talks about what it was like for her. And she talks about it's sad, terribly, horribly sad, how well wish versus reality captures what goes on before you can acknowledge the full brunt of reality. Just to keep going, you have to pretend sometimes. You can't just sit down on the sidewalk and start screaming. You have to work. You have to get on the subway. You have to pay the rent. You have to keep going. And she talks then about bullying incidents that she'd lived through. So this is just one example of a chapter. These are some chapter excerpts. For example, possible selves is one that goes into, if we think about the very title of the book, Finding Your Best Self, it's about this notion that we have better and worse version of ourselves. And trauma and addiction tend to pull out the worst versions of ourselves, but they can also pull out the best as part of recovery. And we're trying to help people move toward that best self. So here, it actually uses a wonderful sort of concept from sociology and social psychology. It partakes of, it was based in an exercise by Marcus and Nurius, sort of dreaded and the self they hope to become, the self, let me say this more clearly, the example of who I hope to become and who do I dread becoming. And it's a very powerful exercise, especially because it's not just who I hope to become, but equally profound. And for many of these patients, even more profound, who do they dread becoming? They dread getting divorced, becoming homeless, becoming a chronic alcoholic, going to jail, and so on. Those are realities for many patients. So here, it's an exercise where, again, it's done in a relatively simplified format, helping them work on it. This is from the excessive behavior scale, where the first part, part A, is where they identify any behavior that might, either yes, maybe, or no. Is it excessive for them in the past month? And as you can see, we have all kinds of things here. The maybe is a very important piece because often if you just ask them yes or no, they'll be like, no, I don't have a problem. Well, maybe is included, they'll sometimes endorse maybe, and often those maybes are, in the end, a yes. So all kinds of things, electronics, body improvement, nervous habits, things around money, things around relationships, and so on. And then these are the seven questions that they're asked to try to explore. Is that behavior truly an issue? This is not diagnostic, it is just a screening tool, but in the end, basically helping them become sensitized to whether they might have it. Body and biology, there's certainly been some wonderful work on the connection, the mind-body connection, in both trauma and addiction. And this is just an excerpt that's a questionnaire about their relationship with their body. And it goes into everything from physically oriented addictions, which again are mostly behavioral addictions other than substances, also aspects related to, that come from trauma often, which is issues around sex, issues around self-image, body positivity, following up on medical care, and so on. So just to give a flavor for what some of those are, I'll just go for a moment to the Seeking Safety website, which will give a feel for basically what you can also download from Seeking Safety. So we just Google Seeking Safety and go to the Treatment Innovations website. What you'll find here is a lot of different resources, including there's some video and audio material from different perspectives. There's the evidences we talked about. Implementation articles can be really useful that go into aspects that go beyond what's in the book. None of that's required, but there have been some publications since the book was published that basically go into, you know, sometimes people ask, well, if you had to just pick a few topics in Seeking Safety, which ones would you suggest? Or how do we do this for males in particular? Or that kind of thing. So just a variety of things. The library more generally has a lot of articles on trauma and addiction broadly by myself and my colleagues. I've been going back for many years and all of it is freely downloadable. I'll highlight for you one thing that I think fits the adaptation topic, which is my colleague Teresa Marsh did some wonderful work as part of her doctoral dissertation on use of the model with indigenous people in Canada. And basically she published several publications describing the training they did and describing outcomes they got and used this framework of two-eyed seeing, like two eyes, E-Y-E, two-eyed seeing, basically looking at it through the lens of the traditional tribal methods and traditions and looking at it through the lens of Western model, which was Seeking Safety and sort of blending the two. And she did beautiful work on that. So just, I think, a really nice example of adaptation. Um, let me go back for a moment. And I apologize. I think you may not have been able to see that. So I'm just briefly going to point you to where this is on this page of the Seeking Safety website. So we were in the library, all articles by year. And as you'll see, you'll find a lot of articles and these are some examples from some of the work we just spoke about. Some of the work by Crisanti on peer-led Seeking Safety is here and so on. I wonder if this would be a good place to pause and go into questions. I can certainly keep going with all kinds of things, but I'm happy to do whatever feels most relevant here. Well, thank you for this, you know, really wonderful talk. You inspired me to recognize the fact that I could implement this in my own practice. So thank you for that. It was something that seemed kind of distant and something that wasn't compatible with being able to kind of be used in individual sessions. So I'm going to do that. But I'm going to start off by asking a question about like your quotations. You know, it's interesting you quote people from like Ralph Waldo Emerson to Spinoza to Janice Joplin. And I'm wondering what some of the honorable mentions were, but I'm going to start off with a quotation. Einstein said, you know, the definition of genius is taking the complex and making it simple. And that feels to me like what you have done in this. And maybe you can comment on, I'm sorry, I have some construction in the background. Yeah, I really appreciate that quote you just gave from Einstein and the concept of it. And I think the idea is, you know, there's a quote I'll just say, a famous quote from Mark Twain that I'll mention as well, which is he was writing to someone and said, I wanted to write you a short letter, but I didn't have time. So I wrote you a long letter. The idea being trying to crystallize and express things concisely and clearly and briefly is much harder than kind of going on and on. And so I really feel very grateful for the background I had as an undergraduate. I was a history major and an English minor, very much focused on the humanities. And my focus on quotations, I think, comes in part from feeling very inspired by some of the readings then, and certainly in the years since then, the power of quotations and the power of writing and how writing can pull people in or it can turn them off. And so in Seeking Safety, there's very much a focus on trying to be lacking in jargon, you know, no jargon, no big heavy scientific sounding terms. Language matters. For example, instead of calling it cognitive restructuring with all respect for what an important concept that is, but it sounds kind of intimidating and very technical. So we call it rethinking. So, you know, and throughout trying to use poignant language trying to make it as clear and simple as possible. And I'll never forget early on when I was presenting and I really had the benefit of several years of implementing the model and watching others implement it and talking about it before it was actually published. It was actually Seeking Safety was 10 years in the making and Finding Your Best Self was probably about five or six years in the making. And basically I remember someone early on saying, well, you know, some of the, I don't know that this is the reading level that would meet a fourth grade education and our clients will not be able to read this and so on. And I really took that seriously because the goal is impact and connecting no matter what someone's education level is. And basically I was very happy to find that even if clients can't always read every last bit of it, they get the ideas because the concepts are simple. Everyone can understand asking for help, taking good care of yourself, setting boundaries. So even if they can't read at all, it's sometimes been done with people who are illiterate or very low cognitive ability, they can get the concepts. So just coming back, Chris, I really appreciate the quote and the concept. It took me a lot of work to try to get it as simple as I could. Yeah, we live in such a complex overstimulating world. This is so refreshing. And it's really amazing how this could be implemented by anyone. And it requires minimal training. But there's obviously so much wisdom in it. So thank you for that. Thank you, David. I think David was going to read the next question. Sure. So this is from Jennifer. She says, thank you for your talk. Wondering how you believe the program could be best utilized for patients with TBI or other cognitive vulnerabilities, which seem to be more and more prevalent as people grow older and can be unrecovered on multiple levels. Yeah, fantastic question. Certainly TBI occurs both in addiction and in trauma. And it has become increasingly recognized, in part due to the wars, people coming back from Iraq and Afghanistan, but also more broadly in treatment programs. So wonderful that it is now focused on. It is much more commonly assessed than it used to be. That being said, it is a challenge. It is a challenge of how do you work with people who have some limitations in their cognitive abilities. And with seeking safety and finding your best self, what I would say is this is part of where the message of adaptation comes in. Both models were built for adaptation. So what people naturally do, I think, as long as they don't feel constrained or that they're doing something wrong, and with these models, you're not, is to adapt it as fits your population. So to take that example of TBI, it would be slowing down the material, definitely not covering a lot of stuff, guiding them for what to look at. So if we're dealing with, let's say, people who have high cognitive ability and, you know, strong functioning and so on and so forth, we might ask them, you know, take a look through the materials and, you know, what do you want to work on? If you're dealing with someone with TBI or people who are more distractible, for example, adolescents, what you might do is say, let's turn to page 25 and let's take turns reading aloud a couple of sentences. And with this material, because again, each of the chapter titles, the concept is simple. They don't have to read every last bit, but it can be a launching pad into discussing the topic. So certainly slowing it down, giving only as much material as they can absorb. With people with cognitive impairments, doing a lot of repetition, people have done some wonderful things over the years with seeking safety and increasingly with finding your best self as well. They'll do art projects. One program did, for example, holiday-based themes. So for St. Patrick's day, they would have little cutouts of shamrocks. And on each shamrock, the patient would put a favorite coping skill, whether from seeking safety or from their own experience. Valentines and so on. So many different versions. Creating games. I really try to, when we do training on the model, we try to build in games because games go to, everyone has a childlike heart, and games can be great for reinforcing the material, especially for people with impairments, to be able to sort of do it in a way that's fun, where they don't feel that they're sort of being talked down to in any way, but more engaged in a way. So whatever ways are possible, using ancillary methods like games and artwork, doing collages, et cetera, and just really adapting based on the population. So one of the things, I'm fascinated by the name Seeking Safety, how you came up with that, because, I mean, I don't know, sometimes we don't always associate addiction with safety issues, but the more we learn about the neurobiology of addiction, and specifically incentive salience, everybody knows that incentive salience is about the motivation to avoid, I mean, to seek pleasure in the reward circuit, but there's emerging research that's focusing on how the same dopamine and incentive salience helps us to sensitize ourselves towards avoiding pain and other things, other circumstances. So that's the activity of dopamine, and this just fits in so nicely with your work and the idea of seeking safety with a new understanding of the neurobiology of addiction. Wow, that is a powerful statement, and I really appreciate it, especially not being a neuroscientist myself, but certainly appreciating that domain and the increasing findings, both in the trauma field and in the addiction, about those kinds of phenomenon. And, yeah, I definitely agree. I think, you know, when I think back to giving a title to the book, it's kind of a sort of funny story that basically what happened was I created the topics, most of the topics, and then I was trying to find a title for it. And someone said to me, well, what's the key concept if you had to say what's going on across the whole thing? And, you know, it struck me that safety was the core idea. And basically what, you know, and it ended up converging with the Judith Herman work. I feel almost embarrassed because I should have started with that, but it was actually later. But I think the concept of safety, long story short, is it's such a rich, deep concept. And it goes really to, when you think about survival, it goes to one of these core aspects of human survival, that safety is part of survival and processes can go awry, certainly in addiction and also with trauma, where people end up getting reinforced internally and externally, you know, biologically and also socially for doing things that are unsafe. And unfortunately what happens with chronic trauma and addiction is it's incredibly reinforcing in the wrong direction into unsafe behavior. So it's almost like a, and I'll use this phrase loosely, a rewiring of the brain to be able to go for safety and go for survival. And, you know, patients describe it beautifully that they got so used to chaos that that felt normal for them. The adrenaline of drama, the adrenaline of unsafe relationships that felt normal and being calm and peaceful and functional feels weird and almost uncomfortable, but they can retrain themselves. And typically what they see is that the benefits are huge for themselves and also for the people in their world, like their children. Thank you, Chris. I'll go to the next question. This is from Melissa. She says great presentation within the psychoeducation component of these two models. Does either one include a reference to the adverse childhood experiences assessment? Yeah, very glad that that is brought up because certainly the, I think people are familiar, but just the quick thumbnail. So the adverse childhood experiences study is one of the most pivotal studies in the trauma field. And learning about it as part of what's called trauma informed care, trauma informed care being one of the major public health achievements of the past 20 years. So just briefly trauma informed care for anyone who might not be aware of it is the idea that traumatized people show up in every possible settings because trauma sadly is epidemic. The majority of Americans and really the majority of people in most countries experience trauma. So the idea is that even staff who aren't delivering direct therapy or counseling still need to be aware of trauma, trauma needs to be assessed and trauma needs to be handled sensitively. So it's been a huge advance to focus in that way, rather than some of the old style methods, which were more blaming, more, you know, use of seclusion and restraints and hospital settings, you know, one could go on and on. So trauma being sensitive to it is key. And the study adverse childhood experiences came out basically in the late nineties or early two thousands. Felitti and colleagues basically took tens of thousands of patients from the Kaiser Permanente healthcare system in California, who had records of their healthcare and had them fill out this scale, this adverse childhood experiences scale, which is easily found online. It's a publicly available brief scale that you can find. And the key finding from that study was that the more people had endorsed, said yes to adverse events in childhood of all kinds, you know, traumas growing up in a family with addiction, growing up in a family where people were incarcerated, you know, really core questions, the more of these they endorsed, the more likely they were to have both mental and physical health problems throughout the lifespan. And it was an incredible finding that really helped cement the idea that trauma impacts both the mind and the body and brought much greater attention in physical healthcare settings, for example, to trauma. So a great study, there's a whole website. I think it's ACEstudy.org, but if you just look for ACE study, you will find it immediately. Coming back to the assessment, which was the core question. So I'll tell you my honest read on it, which is I certainly have huge respect for the study, but what I've seen programs do is they take that scale and use it as their trauma scale. And that is problematic for a couple of reasons. First of all, it only addresses childhood events, but many of the people we work with experience traumas in adulthood, whether that's military trauma, whether that's a natural disaster, whether it's a car accident, car accident being the most common trauma in the U S population. So the ACE questionnaire doesn't get at those. And that is a problem because when we're trying to assess trauma, we do want to get, you know, as broad as possible and identify really what has this person lived through. The second thing is there are aspects that it, it just doesn't address. So it, it, it hones in on some that are key, but also others, some of the ones we just named that people may experience as children, but aren't necessarily based in the family. So car accident, as we just said, natural disaster, a fire, a terrorist incident, none of those are captured by that scale. And so I think, you know, I'll just say one other thing about assessing for trauma that I think is key that what people used to do, and you'll still see this in some places, they'll try to interview the person. Oh, have you been molested? Have you had this? Have you had that? And it's very hard for a patient to look you in the eye and say yes to those questions. So one of the key findings in assessment of trauma is it's actually better to do a self report, a pencil and paper measure, or now we have, of course, online measures. So it's better to do it that way where the person can see a long list of things and then say yes or no, or not sure, whatever they're going to say about it. So that is going to identify the most number of traumas. And so if you're going to do that, you really want to use a scale that will assess very broadly. So there are other scales out there that do have broader assessment of trauma. I'll just name a couple of them. The VA, Veterans Affairs, for example, uses the PCL, the PTSD checklist, which has a scale that goes with it that identifies different types of trauma. So if you just Google PCL, you'll also find the trauma scale you can use. The PTSD checklist just addresses the 17 symptoms of PTSD, but the precursor scale addresses traumas themselves, meaning the events, the child abuse or the assault or whatever it may have been that may have led to PTSD. Another scale is the stressful life experiences scale. There are other scales out there as well, but anyway, that's my long reply to adverse childhood experiences scale. Thank you. I think you're referring to the life events checklist that goes with the PCL. So I posted a link into the chat from the VA website if people are interested in that. And I use that frequently. So it also allows like the final option, number 25 or something like that, essentially says if there's something that happened to you that wasn't covered with all these other ones that we just asked you about, you can write that in at the end too, which is helpful for people. Great. Thank you for posting that. That is exactly the one. Sure. Chris, I'll just go to the next one. Let's see. Jesse says, are there certain coping skills that you tend to start off with in seeking safety or ones that might be more foundational for building off of? Yeah, that's wonderful because I think there are, and certainly here again, it'll depend on who you're working with. One of the things we do in both seeking safety and finding your best self is we give you're doing, especially for individual, it lends itself less so to group, but you can actually give the patient the table of contents. There's a whole list of these topics. You can grab them from the handouts here, whatever method, and you can give it to the patient and say, which of these interests you? Now they may not ever understand every last one. They may not know, well, what is integrating the split self? Whatever. Some of them they won't understand, but a lot of them they will. And sometimes they will have a preference. And it really goes to the empowerment nature of both models. We're always trying to empower the patient as much as possible. Empowerment being the opposite of what happens in trauma and addiction where they're disempowered. Basically, one method is that. You can just have them choose and so on. Another method, and especially for groups where you don't want to get into a big debate between people around which one to do, I think some of the core ones, certainly safety where they get the seeking safety model where they get the list of over 80 safe coping skills. We really think of that as something that they can come back to throughout treatment and really ongoing in their lives. Coming back to that core list of safe coping skills. So the topic safety and certainly covering what is safety, what does that mean to them? Having them imagine safety. It's just really core. A second one is grounding because it is so usable and it's so concrete. So that's an example with, for example, TBI patients who typically may be more concrete, less able to do abstraction. Grounding is a great topic because so much of it is sensory. And patients will sometimes say, I wish I had learned this 20 years ago. I mean, it seems so obvious to us, I think. It's easy to underestimate that being able to just shift out of a negative mood state is often not easy for people. But if you give them the skills for it, it really helps them build a sense of confidence. It's like, oh, my gosh, I think I can do this. So grounding is another one. And then from there, I would basically say if they don't know what trauma and PTSD are, I think that's an important topic to get the education. And it really does build buy-in. Again, because then it can be to help motivate them to work on the addiction as well as the trauma. So PTSD, if they don't know about addiction, certainly the substance abuse topic I think is key. From there, I think it really just depends. Asking for help, I guess, would be another one. In this day and age where a lot of people are stressed and isolated, I think the topic on anger, it's called healing from anger, is important because people often don't know what to do with their anger and their rage. So I would say those. I think probably the last question we'll have time for is wondering about strategies you recommend to keep folks from repeatedly reporting their resentments from the past, the blame, the wrong they can't get past. And I think this ties into something that you brought up before, which is don't move into the past narrative and to focus on the present. So perhaps that applies to what you're talking about. Yeah, definitely. And I mean, it's such a fine balancing act because on one hand, we definitely want to validate their experiences. So often they have been invalidated in their families and their communities and sometimes in treatment. So certainly validation is the starting place. And I always go to, I'm such an admirer of Marsha Linehan's work, dialectical behavior therapy. And one of the core strategies she talks about is validation. So validation is key. Always starting with that, even if you want someone to move off from whatever they're focusing on. So I always start with if a client, let's say, is coming back into some sort of rumination or repetition of the same theme, it might start with, you know, I really get that that was profoundly important to you and it is really important. And then we move on to the, you know, dot, dot, dot. And now here's where we try to shift it. Now the shifting can occur in any number of ways. For example, sometimes if someone's doing group seeking safety, it really may be that the person could benefit from individual trauma therapy and they could be doing that concurrently. They could be doing EMDR individually while they're doing group seeking safety. So I might say something like, you know, it really sounds like it would be good for you to have a place to talk about some of these events from the past. So let's talk about a referral to that kind of care. That could be one option. If they're not perhaps ready for that kind of work or you think it wouldn't be beneficial, another option is to help bring them back to the present, doing it in a way that, again, is very compassionate and validating. So I might say something like, you know, I really hear that that event that happened when you were 12 was devastating. Let me ask you, because in seeking safety or finding your best self, we're focusing on how it impacts you now. So can I ask you, how is it showing up in your life now? For example, in the past week or in the week ahead, do you see that it's having an impact on you? And depending on what it is that they're focused on, I'd be a little more precise there. Maybe it's impacting their relationships or their behavior or whatever it is. So that question of after the validation, the how does it impact you now in the present is a way to bring them back. And when you bring them back to the present, typically now they're going to need some sort of coping skill for it. You know, oh, it's my, you know, it's my mother who keeps hounding me about telling me I'm raising my kids wrong and, you know, whatever, blah, blah, blah, we're always arguing and blah, blah, blah. Wow, it sounds like it's really hard to have that kind of stress with your mother. Let's talk about how you can cope with that. Let's talk about maybe it involves setting a boundary, you know, and here's where you'd want to get, you know, their input. Maybe it's setting a boundary. Maybe it's being assertive. Maybe it's, you know, X, Y, or Z, whatever the coping skills might be that address it. So, you know, how does that influence the validation and then referral to care as may be appropriate and or how does it impact you in the present and then moving into coping skills? Well, thank you so much, Dr. Najevitz. This was really a wonderful presentation. And we're grateful that you spent some time with us today. I just wanted to kind of remind the group that, you know, please fill out your evaluation in order to get your credit for CME. And we hope to see you soon. But thank you again, Dr. Najevitz. My sincere pleasure. Bye, everybody. We'll see you next month. Bye. Dr. Humphreys will be, but not next month, in January. We're off because of the AAAP meeting next month. And in January, it'll be Keith Humphreys talking about 12-step

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