CASE STUDY: Integrating SSP group delivery in an inpatient Level One psychiatric facility
CLIENT BACKGROUND
Name: Eight inpatient people at a Level One psychiatric facility
Age and Gender: Women and men aged 26 to 62
Program Delivered: Safe and Sound Protocol (SSP) Core (Hours 1-5)
This group of patients sought 45-day inpatient care at The Meadows to reset their nervous systems and address trauma-related behaviors and emotional responses.
The patients’ medical presentations included:
- Mood disorder
- Depression
- Anxiety
- Obsessive compulsive disorder (OCD)
- Autonomic dysregulation
- Post-traumatic stress disorder (PTSD), complex PTSD, developmental trauma, shock trauma
- Substance addictions (alcohol and drugs) and process addictions (sex, gambling, work)
- Disordered eating
- Sleep disturbance
- Complicated/disenfranchised grief
- Racialized trauma
- Untreated codependency
- Disconnection from an embodied self
The patients consisted of:
- Two CEOs
- Two combat veterans
- Two performers (singer and artist)
- A life coach
- A stay-at-home mom
Treatment outcome goals included:
- “To experience greater peace.”
- “To stop living in reaction all the time.”
- “To stop drinking myself to death.”
- “To be more present with myself and family.”
- “To stop living in fear.”
- “To get rid of my self-hatred.”
- “To learn to love myself.”
- “To learn to accept myself.”
- “To figure out who I am.”
Setting these intentions helped to provide a container. The patients wanted to explore the factors getting in the way of their stated intentions. They hoped to reduce and potentially eliminate unfavorable symptoms, sound sensitivity, anxiety, emotional reactivity, rage and shame, fear of social situations, and fear of people. More specifically, they wanted to decrease sensitivities to sounds and triggers, decrease the internal noise level, frequency rating, intensity, and duration.
rating the intensity frequency and duration of sound sensitivity
For this round of the SSP, the goals were aimed at supporting a reconnection to self, and reintegration with family, social context, and work. Because symptoms typically come from a deeper place of disorganization, supporting overall increased coherence and organization was also an objective.
IMPLEMENTATION OF THE SAFE AND SOUND PROTOCOL (SSP)
Meadows Behavioral Healthcare invited Ana Do Valle, a longtime and experienced SSP provider, to train their staff and support the therapeutic group of eight patients and four therapists; they found that a two-to-one patient-therapist ratio worked well. Delivering the SSP at the group level allowed The Meadows team to reach more patients while maximizing their resources. Each staff member received about 24 hours of in-person training over four days for two hours three times a day.
The SSP was delivered in a group setting to patients at The Meadows’ main campus in Wickenburg, Arizona. The room was spacious with large windows to allow for orientation. The eight patients sat around a rectangular table while listening to the SSP.
The supporting method of delivery was SEGAN, a healing model that stands for Sensation, Emotion, Gestures, Action and Narrative, which included the use of movement and art. It also uses the systematic monitoring of felt sense and felt shift through visual charts. This method is based on the use of healing art, poetry and movement to defragment the narrative of self.
In addition to the patient healing group, there was a second therapeutic group for 16 Meadows staff members who wanted to become more familiar with the SSP. The patient group went through the SSP over the course of five consecutive days; on the fifth day, the staff conducted the session themselves without Ana guiding.
Each daily group session lasted 90 minutes and took place in the early afternoon, with breaks as needed. There was systematic monitoring of felt sense (through visual charts) every 15 minutes, once at the start of the session for the baseline then pausing at 15-minute intervals. After an hour, they read poetry that they created post-listening.
While the SSP listening sessions lasted one hour within the daily 90-minute therapeutic session for most, one patient required a 20-minute break during hour three of listening. This patient became somewhat activated, rapidly removing her headphones and throwing them down on the table. She was supported as she paused the music and exited the group room with one of the clinicians. The break consisted of titrating the experience with a walk and some movement in nature, and she was able to discharge some energy through vocalization and movement.
Patients attended their SSP sessions following their neurofeedback (NFB) sessions. Both the SSP and NFB were interventions selected by the patients. They are both non-invasive and support increased presence, targeting bottom-up processes, specifically the brainstem region, quieting fear circuitries associated with rage, shame and fear, and supporting the neuroceptive experience of safety. The NFB supports the elimination of an overactive fear response and the SSP supports social engagement and an increased sense of safety. The absence of fear alone is not enough to establish safety, which may be why NFB and SSP work very well together.
RESPONSE
Throughout the week of SSP intervention, patients were also attending their individual trauma sessions. Both patients and staff reported an increased ability to process traumatic and sensitive content more readily without experiencing overwhelm. Clinicians also reported SSP patients exhibited a more pronounced ability to be with their experience without getting overwhelmed. Patients were able to participate in Somatic Experiencing (SE) sessions, sand play therapy or individual counseling sessions in a way that was more resilient, grounded and meaningful to their personal experience.
Patients’ pre- and post-brainwaves looked more coherent and organized. One patient showed a significant decrease in theta wave activity (slow waves), supporting “less spaciness and dissociation,” and having an “easier time concentrating and staying focused during lectures.” The clinical team noted that excess slow wave activity, especially frontally, is oftentimes a biomarker for developmental trauma.
Another patient had a significant decrease in beta wave activity (fast frequency), which translated for him as “a lot less anxiety.” This patient is exploring this new experience that feels unfamiliar and continues to ask himself, “Who am I without my chronic worry and fear?” His ability to tolerate expansion was titrated in his individual sessions. His startle response subsided and was no longer exaggerated.
Patients became more present and improved in modulating their behaviors and emotional responses. They enjoyed sharing their experiences and improvements with other group members.
Examples of experiences include:
- Being able to play the piano and sing.
- Being part of a social group and communal engagement.
- Expansion
Primary therapists from The Meadows clinical team reported the following impressions of patients:
- More present in the group, more engaged.
- Greater capacity to be in [the] here and now; brainwaves also reflected this.
- Decreased symptomatology of agitation, depression, anxiety and restlessness, and less pressured speech.
- Increased capacity to manage impulses and triggers; increased ability to pause between stimulus and response.
- Significant decrease in sound sensitivities, allowing them to be more present to their internal experience.
- Significant increase in internal organization, as evidenced by a more coherent narrative, and being less fragmented and tangential in their presentation.
- More capacity to hold complexity of all realms of their experience, and to notice their heart rate increase without merging with the activation.
- Increased capacity to tolerate distressing emotions and experiences.
- Increase in affect regulation, tolerate state shifts, broader emotional range.
- Increased ability to self-reflect.
- Overall increase in mood, energy, clarity and sleep; some shifts were more pronounced than others, some more subtle.
- Able to establish coherent narrative about family of origin history and adult traumatic experiences.
- A return to passion and hobbies, such as playing the guitar.
- Significant decrease in tangential thoughts and narrative.
- Ability to spontaneously orient and shift from defensive orienting response to more exploratory orienting response.
- Social engagement system more online, with increased eye contact, brighter affect, increased facial muscle activity, and softer, increased smiling
DISCUSSION
Experiencing the five-day listening in conjunction with the SEGAN method, staff training and session participation allowed the staff to become part of the experience and co-regulate. There was improved communication among all team members as they monitored and provided feedback to the staff delivering the SSP, allowing for the process to be coherent and meaningful. A sense of camaraderie was felt among the group as staff were more available for connection with themselves, each other and patients following the training and felt sense experience.
The group delivery normalized and created a positive bond between the patients. After the SSP sessions, participants would proactively provide feedback on their daily experience and in individual therapy sessions.
The Meadows’ clinical team shared that for individuals with severe mood instability, rage and bipolar in an inpatient level of care, the SSP within a group setting should be titrated on day two of listening. For example, 30 minutes in the morning and 30 minutes in the afternoon.
This case study illustrates the implementation of the SSP into an inpatient level of care. This was the first group at The Meadows that experienced the SSP in this delivery model and in this setting.
After witnessing the benefits, shifts, effectiveness, and efficiency of this group process, this SSP delivery model now runs weekly at The Meadows.
