Date: 6/17/2019
Associate Name and Discipline: Laura D. Wiley, LCSW
Client Name and Age: Becky, a 49-year-old female and Lynn, a 9-year-old female.
Clinical History Before SSP
Becky is a 49-year-old mother who lives with her 9-year-old daughter and the child’s father in a trailer park in a very rural part of Maine. Her husband works in a bakery and Becky cleans rooms in a hotel. They barely make ends meet and have significant financial stress. Becky is able to come to therapy due to state health insurance coverage. She came to me because her previous therapist was moving away.
I began working with Becky in May of 2015. She attends therapy weekly and is very committed to attending her therapy sessions. She comes to therapy very disheveled in appearance. It is not unusual for her to have one pant leg tucked into a sock and the other over the other sock. She could be wearing a knit hat with a tassel on top (much like a child’s hat). She could be wearing worn out sneakers where there is a big hole under the toes and the sneaker makes a flopping sound when she walks. And when she walks she does not pick up her feet. Often clothing does not match nor fit correctly.
Becky also presents very quiet. Sometimes this is an indication of dissociation. In my office, she moves in and out of a dissociative depersonalization state where she is detached from her thoughts and body. She will sit in my office and not be able to formulate words, nor connect with her body such that she is feeling numb and lost. She gets overwhelmed with thoughts and images. When she is not dissociating, she rarely initiates dialog but will open up as the session proceeds.
Though Becky presents very childlike, she is in actuality extremely bright, perceptive and reflective. Her movements are often very slow and reaction times (to questions or situations needing an intervention) can be extremely spacious. As a result of this, she is often misunderstood and dismissed by others in her life.
She has many physical symptoms of aches and pain in her limbs that sometimes produce sensations of extreme heat that is uncomfortable for her. She also reports pain in joints, headaches, tightness in chest, stomach nausea, inability to sleep, compulsive binging on food, acute and chronic pain is a real problem for Becky.
Organization is another very difficult challenge for Becky. She is unable to keep her home picked up. She reports significant clutter in which part of her problem is she does not know where to put things. She is unable to get herself to open her mail. Once she does that, she can not respond to it (ie pay bills, follow-up, make appointments, etc.). Her previous therapist used to have her bring in her mail and they handled that during her therapy sessions. Now she has what is called a Daily Living Specialist that comes into the home and helps her organize her space.
Some other symptoms that Becky suffers are difficulty sleeping, depressed mood, overly negative thoughts and assumptions about herself or the world, high anxiety especially around social situations, low self-esteem, hopelessness, powerlessness. The only way Becky was able to overcome her anxiety to motivate herself to get and maintain employment was because she wanted money to help her daughter be able to go to a private grade school. As a result, Becky has had steady employment for 3 years. Every work day is a personal battle with enormous anxiety because of all her insecurities. She hangs in there with the job. Unfortunately, her daughter wasn’t able to be in private school. Becky loves her daughter so much that will find the courage within herself, which she can’t usually access for her own behalf when it comes to her daughter’s needs. It may be obvious at this point, Becky has a serious trauma history stemming from her childhood.
Becky’s largest complaint is her anxiety. She lives in and with constant panic attacks and is terrified chronically. She often speaks about how tormented she feels by the anxiety and how desperate she wants it to stop. This is her primary goal of the therapy. I have diagnosed Becky with complex trauma (PTSD) and am treating her clinically from that perspective. Her psychiatric medication provider has diagnosed her with Schizoaffective Disorder. I believe that diagnosis matches Becky’s presentation as well.
Clinically, I work with Becky on creating a safe space in the therapeutic environment. I introduced some somatic techniques and body-oriented grounding, relaxation and calming skills to help her tolerate her emotional experience and reduce the intensity. I work with her on her thinking/cognitive distortions and reframing her thoughts. I am helping the client to work with thoughts and images to help reduce her anxiety states. We also do a lot of skills development in the categories of Distress Tolerance, Emotional Regulation, Interpersonal Effectiveness and Core Mindfulness to help her with the management of herself and the environment. These skills are drawn from a Dialectical Behavioral Therapy (DBT) approach.
We are making progress but very very slowly. In the early days of the therapy, being able to speak freely and be heard was a significant and healing experience for Becky. She often spoke with an appreciation for space and opportunity. It appeared that this was the first time she felt really safe to express. Now she is able to do some self-soothing skills at her home like soaking in a warm bathtub or taking a walk. She says she practices deep breathing exercises but “they don’t help.” Furthermore, Becky seldom comes to sessions in a dissociative state nor enters into one during our sessions.
Implementation of the SSP
I had Becky read the Beginner’s Guide to Polyvagal Therapy (from Deb Dana’s text). Unfortunately, Becky felt too far gone to feel like that would help her. Hence, she reported to me that she was not interested in any Polyvagal interventions. However, when I presented the SSP with the picture of the sound waves going through a normal ear and a disordered ear, she perked right up. Her first impulse was wanting this intervention for her daughter. She was open immediately to trying the SSP. She was resistant to setting a goal for the SSP because she was not sure what to expect. When I insisted on a verbal/written goal she stated she wanted to sleep better and have less anxiety and panicky experiences. I met Becky in my private practice office on Monday, my day in which I do not meet with clients. I oriented her to the equipment (the walkman) and how to set it up and where she would have her SSP sessions, which was in a small room adjacent to my clinical office. She was told I would help her with the equipment today but Tuesday through Friday she would need to do it herself. She was very anxious about being able to operate the Walkman mp3 so I reassured her that Tuesday through Friday if she came a bit before the hour that I would be available to assist her between my clients. Next, I showed Becky how to operate the equipment and insisted she does it herself to start the day 1 protocol. She was able to follow the sequence and get herself going. She sat in a comfortable chair in a small room that had very little stimuli. I offered her some paper and markers if she needed to occupy herself during it. My instructions to and for her though were for her to sit still and relax and take in the music, actually listen to it.
I did paperwork in my office while Becky sat through the day 1 protocol. I checked in on her occasionally and she was sitting peacefully with her eyes closed. She did not use the markers and paper. At the end of the session, she came into my office. She was unusually chatty with small talk of a lighter content than during her more serious clinical sessions. Next, I gave her instructions that she was to do this same routine tomorrow by herself and if she needed me she could knock on my door. She went on her way Tuesday she did not need nor make contact from me. I peeked in on her to just see with my eyes how she was doing. She was sitting back in the chair. The chair was high enough so it had a headrest, her eyes were closed. She left without seeking me out leaving behind a small picture that she drew with markers sitting on a table in the room.
Wednesday, Day 3, she sought me out before getting started and asked me if she could lay on the floor because she had a headache. I affirmed that she makes herself comfortable in any way she felt she needed to. No more contact with her for that day. Thursday Day 4 I had no contact with her at all. I only know she came because the equipment had been moved and look used.
Friday, Day 5, she came without seeking me out. I had heard her come in. About 20 minutes into her session and between psychotherapy clients for me, I peeked in on her. She was not there and neither was the headset. She left a note stating she was sitting in the hallway because it was too noisy (see picture attached). After my session with my psychotherapy client, I checked in on Becky and the headset was returned and she was gone.
Client’s response to the SSP
Becky’s response to the SSP is as accurate as I could get it. The following are very close to exact quotes.
I asked, “Did you notice anything during or after the 5-day Safe and Sound Protocol?” — “It (the SSP) did have an effect. I am a very nervous driver… I do not know what people are going to do and this makes me very anxious. I am finding that I am not having as much trouble driving… I am not gripping the steering wheel as tight.”
“Another very strange thing happened: Now, when Lynn (her 9-year-old daughter) gets upset I feel like I am handling it better. The anxiety that I felt when she would have upsets has diminished, it is gone. I am calmer. For example, one day she was going on and on with distractions and not getting ready for school and would just not stop and focus and it was getting later and later and the pressure was building to get her ready for school. I raised my voice and scolded her. You know Laura, I never do this. I probably did this three times in her whole life. It did not help and it was probably a very stupid thing to do but I was trying to take control of the situation. I had had enough. This was very unusual for me. I almost never exert force to get her to mind.”
“Another thing I noticed. Its weird this change [I am going to describe] and I do not know if it is connected to the SSP: Merging onto the highway… I was giving a lady a ride home from work and I have to look
over my left shoulder to see the traffic and I can’t move my neck very well so I ask her to look for me. Well, she says don’t go then go go go… I would normally get very agitated by that. Instead, I stayed calm and waited until I was ready to go… I took control of the situation.”
“Another strange thing I noticed: Taking bottles to the grocery store. This is very stressful for me. Typically I have my caseworker do this with me at home. We will put the bottles that are in the trunk of my car into the bag then drive to the redemption center to return them. This week I did it all by myself and I bagged the bottles in the store parking lot! I usually get extremely frustrated and say to myself ‘why is no one helping me’ or I get very preoccupied with people looking at me. I would have never done this before. I would have been paranoid people were watching me. I even noticed halfway through and said to myself ‘I can’t believe I am doing
this’.”
Conclusion
In addition to the changes Becky reported below, I have noticed some subtler changes during the therapeutic hour. She is initiating the focus of the treatment hour and her voice is more rhythmic with an increase in strength. I was surprised by the changes. I would not have expected an increase in self-confidence nor initiating any action steps towards taking control of her environment. She clearly made significant gains using the SSP in just 5 days! I would consider this almost a miracle.
Becky filled out an SSP Checklist of questions before she took the SSP and then filled it out again 2 weeks after the completion of the SSP. Out of the 36 questions, she had symptom improvement on 25 of those questions (69%) and reported no change of symptoms on 11 of those questions (31%) and reported none of her symptoms worsened (0%).
Becky’s current medications:
Olanzapine – 1 month prior to SSP. “I was taken off this because it made me tired.”
Geodon – newest addition. “I was put on this because I needed more energy.”
Gabapentine – “this helps me with my pain level in my body.”
Becky reported to me that started a new psychotropic medication (Geodon) 3 weeks prior to the SSP protocol. She took the medication for one week and started having discomfort in her stomach so she stopped taking it (without consulting her medication provider) for approximately one week stating “it was like blackout pain, intense headache beyond nausea I had to stop it, my balance was off I could not stand up or walk.” She said “my panic attacks came back so I had to try that medicine again. I needed to give it another try. I had more nausea and headaches but they were not as severe as before.” This all occurred 1 week before she participated in the SSP.
She reported to me that she started having a headache on Wednesday Day 3 of the protocol. She said she had a migraine that lasted 9 hours and she could not get comfortable. She also reported that she started taking Magnesium during her 5 day protocol. Though it may be difficult to differentiate, I do not believe the changes she experienced surrounding the 5 day protocol were due to the medications. I have watched Becky go through many medication changes in the past 4 years of our work together. During that time, I observed that the medications have significantly helped with pain reduction and thought blocking. I had not observed that the medications have ever made any significant changes to her self-confidence, self-assurance or ability to feel more courageous. I asked her if she would be willing to take the protocol again and she said yes.
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