10 Things I Learned from Wounded Warriors Canada Trauma Exposed Professionals Course

Below I review the 10 most important things I learned from Wounded Warriors, draw conclusions and provide my insights into putting these ideas into practice. If you’re interested in Dr. Black’s teachings or this course, make sure you head over to the Wounded Warriors site. They do great work and provide support for a lot of veterans, first responders, and other uniformed professionals. Let’s get started!

1. Society Expects and Rewards Suppressed Emotions
2. Uniformed Professionals are Different Than Regular Civilians
3. What a Traumatic Event Versus an Upsetting Event is
4. Exposure to a Traumatic Event doesn’t Mean Traumatization
5. The Therapy Handbook Doesn’t Always Resonate with Uniformed Professionals
6. Structure is the Antidote to Chaos
7. Changing Non-Declarative to Declarative Memory Gives Control
8. Let the Trauma Line Guide Therapy
9. Create a 3-Part Narrative
10. Self-Care or Just Good Practice
11. BONUS – BETR Model

Wounded Warriors Canada is an organization that focuses on the mental health and well-being of veterans, first responders, and all uniformed professionals as well as their families. One of their main goals is to make trauma-informed uniformed professional-specific care a standard. This means they create great educational content and as such, I took a course taught by Dr. Tim Black, R. Psych.

1. Society Expects and Rewards Suppressed Emotions

OK, so on one hand it makes sense right? Call 911 and the dispatcher says to you, “Sorry, I’m having a really bad day. We just had 3 calls in a row where someone died.” not really what you need to hear on the other end when you’ve just been in a major crash. Then, the firefighters arrive on the scene and one of them is crying because they just performed CPR on someone who was not revived. Do you have a lot of confidence in their abilities to help you in your situation? Likely not, so keeping emotions locked up makes sense during a call and when actively on duty. But when does that firefighter or dispatcher get the opportunity to process the horrors they have seen?

As my husband mentioned, there was no formal process. He often said he wasn’t ready to process the call at that time – maybe he was too tired or maybe he just hadn’t come down from the adrenaline rush of the call. Either way, the researchers with Wounded Warrior suggest a 2-2-6 approach. 2 days after a call, 2 weeks after a call, and 6 weeks after a call, review, and process using the BETR Model (see the bonus Learning). This might not be needed for every incident and maybe that doesn’t fit best with every field or department but having a more structured approach ensures that processing critical incidents are a regular part of attending a call.

This doesn’t just apply to fire. Think about doctors, nurses, and PSWs who have a terrible incident and then move on to the next patient. Or a dentist or hygienist who just spent hours working on one patient to then need to go on to the next. How about a police officer/security guard who had an altercation with someone trespassing that was particularly taxing? Or the military professional/veteran who experienced the sudden death and/or major injuries of 5 of their brothers/sisters. The list goes on. Processing the human aspect of high-intensity situations needs to be a part of the job. And it’s up to institutions, governments, and society to make this needed change.

2. Uniformed Professionals are Different Than Regular Civilians

As a regular civilian myself I can appreciate that it sounds weird to say that. But the second most important thing I learned from Wounded Warriors is … my job doesn’t require me to risk my life. That puts me in a different category than my fellow humans who do risk their lives. In the case of anyone who is (or was) a part of the Canadian Military, The Queen’s (King’s) Regulations and Orders for the Canadian Armed Forces, literally provide “unlimited liability”. That means one is willing to give their life if ordered to. That’s a totally different ball game!

When your job carries such a high demand for personal risk – that changes you. You might think to yourself, sure but it’s not like they don’t know what they’re getting into. Again, true. That doesn’t change the profound effect it has on someone. Let’s face it, for this one, if you’re in one of the fields that are military or paramilitary (police, fire, EMS, security) you get it.

Don’t think that medical professionals, dental professionals, PSWs, and the like are excluded from this one either. While they are not at risk of being shot/blown up/or death by fire, they are at risk from biohazards. I think after undergoing a pandemic we all have a greater appreciation for the risk that these professionals go through daily. Once again, they’re on a different level than us regular civilians.

3. What a Traumatic Event Versus an Upsetting Event is

Dr. Black did an amazing job of really solidifying what sets a traumatic event apart from a really upsetting event. I learned from Wounded Warriors how to juxtapose these two concepts. Dr. Black used the example of divorce. Divorce is upsetting, and affects many people, and it often requires some counselling to help individuals strongly affected by it. It is not, however, a traumatic event. Please know this does not make the effects of a divorce (or any other upsetting event) less important and seeking support in counselling can be very helpful and even necessary.

When it comes to a traumatic event though, the difference lies in the limbic (or lizard) part of the brain. Without going into a lecture on the brain and its functions, in this case, we’re concerned with the limbic brain’s control of our safety and survival. The limbic brain controls the 4 Fs (which used to be 3 Fs) fight, flight, freeze, and fawn. (If you’re interested in learning more about the 4 Fs, check out the Human Relations Institute’s article here.) These survival reactions when triggered create a host of situations in our body through physical-chemical release. In a normal and functional response, once the perceived danger is over, the body needs time to filter out the chemicals and process the event.

There are many definitions of what a traumatic event is. Following the Diagnostic and Statistics Manual (DSM-5) it is the exposure to death, the threat of death, actual or threatened serious injury, or actual or threatened sexual violence (American Psychiatric Association, 2022). This definition leaves space for vicarious trauma or trauma that is experienced secondhand from someone else’s experience.

Processing the event is how we integrate a traumatic experience into our being. So, why do some people become traumatized while others don’t? Or why do some events not traumatize us but a specific one does? It comes down to number 4 on this list. The chain of events that can take place leads to traumatization.

4. Exposure to a Traumatic Event doesn’t Mean Traumatization

The fourth most important thing I learned from Wounded warriors lies in repetition. Those who are frequently exposed to traumatic situations are more likely to be affected by them. This applies to uniformed professionals. Dr. Black suggests a few central occurrences which if lined up can greatly increase the risk of traumatization.

Significant limbic system activation – this is that fight, flight, freeze, and fawn (or flop) which occur completely outside of conscious control.

• If the limbic reaction is allowed to completely metabolize and process within a 30-day window or so – then the risk is reduced
• Sometimes completion of the limbic reaction is stopped due to the requirement to attend another call or patient, this can increase the risk

Poor Organizational Response – if organizations are ill-informed, lack training, and lack initiative to maintain and improve post-event mental health recovery it greatly increases the risk of traumatization

• Some institutions are stuck in old ways, “stiff upper lip”, “man up”, “suck it up” etc. these values do not create the atmosphere which fosters the completion of limbic responses. Let’s remember that limbic responses happen outside one’s control and are a part of EVERY human. That means, no amount of “don’t feel it” talk makes it go away.

Repeated Exposure – the greater the number of traumatic exposures the greater the risk for traumatization. When we experience multiple traumas and do not process them it can lead to post-traumatic stress syndrome (PTSD).

• It can be challenging to recognize limbic responses, especially for those taught to suppress their limbic response. The key to helping these individuals lies in teaching them how to tolerate the end of the limbic response. That means experiencing the thoughts/emotions/feelings associated with the trauma and tolerating it.

5. The Therapy Handbook Doesn’t Always Resonate with Uniformed Professionals

The next most important thing I learned from Wounded Warriors is the unique approach that is more comforting to a uniformed professional. The therapist standard is to maintain a humble existence with clients. This means typically we allow the client to remain the expert of their own life. We provide space for them to feel comfortable and safe and for the regular client it works. For the uniformed professional sometimes these “gold standards” come across as incompetence and disingenuous. For this reason, and for this population, it is important to own your competence. It doesn’t mean to over or understate your abilities, just present them and provide the reassurance this client group is looking for.

This is why Dr. Black suggests a 2-Professionals approach. What this says is, you’re the expert in dealing with trauma, attending traumatic events, and helping in your capacity. I am an expert in helping individuals who are experiencing trauma. Let’s work together with our expertise to help you. In this case, demonstrating to uniformed professionals that you are competent, know what you’re doing, and can help them will be extremely comforting and provide a better foundation for therapy to work.

6. Structure is the Antidote to Chaos

In this way, approaching therapy needs to have a similar process. Uniformed professionals require structure and when you consider trauma – there isn’t any. So, as therapists, we need to help them find structure. To do this, be transparent with therapy. Provide a regular framework with which each session will follow. Provide an advance notice for clients regarding a change to the regular process etc. Instead of asking a broad, “How are you?” use the BETR Model to help them structure their response. Instead of starting with a “How was your week?” begin with “How did you find the last session, when we worked on X how were you able to apply it to real life?”. This will help keep the client on track doing trauma work and reduce overwhelming feelings.

7. Changing Non-Declarative to Declarative Memory Gives Control

When considering a traumatized individual, often they struggle to put words into what they experienced, how they feel, and what they think. This comes from non-declarative memory and is often attributed to an experience that has not been integrated into someone’s being. When we tell the story of what we did today that is an example of declarative memory. So the goal of trauma is to convert that non-declarative into declarative memory.

The key I learned from Wounded Warriors? Once the person starts to be able to tell their trauma story, they then start to take control of the memory. This is huge because often, up until this point, the memory had control of them. It popped up at inconvenient times. It made them see, think, smell, taste, feel, etc., something they didn’t want to at the time unchosen to them. So converting the non-declarative into declarative puts them back in control. And that’s a great feeling!

8. Let the Trauma Line Guide Therapy

The trauma line is like a timeline for trauma. It is a map for where therapy is going and the first step in converting non-declarative memory into declarative. It allows an individual to put on paper the things that might be swimming around in their mind. Then they can gain some perspective and ‘see’ what is troubling them.

Completing something like this is challenging for some and nearly impossible for others. Think of someone with complex trauma. Where do they begin? Allow the client to take as many sessions as needed to complete the chart. It is also unnecessary for them to list all traumas, just those that they remember or that bother them. Just a few can be a great place to start. When completing a trauma line, working within the individual’s Window of Tolerance is helpful.

Have the client list the most important, bothersome, or readily remembered traumas, name and date them, and provide subjective units of disturbance (SUDs) score. The ideal is a 0 or 1 and it’s done. This way you can focus on the first/worst/most recent or if time-limited, start with a lower SUDs maybe a 3 or 4 to teach the skill while avoiding overwhelm. Putting down on paper, these difficult-to-articulate concepts were crucial learning from Wounded Warriors.

Make sure you maintain checks (BETR or otherwise), help the client remain connected and in the Window of Tolerance, and do not push them into hyper or hypo arousal.

9. Create a 3-Part Narrative

The ninth most important thing I learned from Wounded Warriors was the 3-Part Narrative and how it fits with trauma. Once again, the 3-Part Narrative allows the imposition of the structure onto chaos. The client should complete the work themself. Avoid the tendency to help or assist as it can create a sense of empowerment for the client. In the future, they know they can do this. As they work on creating a narrative, choose an item on the timeline, break it into 3 parts (often the beginning, middle, and end) get them to title it. Afterward, get them to only explain why they chose these three parts and how it was completing this activity. Try to avoid going into detail at this point. By creating chunks of work, clients can feel accomplished without feeling emotionally and physically drained.

In a future session, deep work on each part can take place. This may need several sessions or perhaps just one but this is where the therapist takes the lead and guides this. Ensure the client completes regular checks (BETR or otherwise) and that they remain in their Window of Tolerance. While delving into each part, let the client choose the mode of delivery they prefer. Some prefer to write, read, or just talk. There is not one right way

10. Self-Care or Just Good Practice

Just as uniformed professionals can experience vicarious trauma so too can the therapist. Recall that hearing of traumatic experiences can lead to trauma (DSM-5, American Psychiatric Association, 2022) and that exposure can increase the risk. By taking proactive precautions, therapists can help reduce our risk of burnout, vicarious trauma, and other work-related stresses.

Dr. Black suggests the 2-2-6 model as well for therapists. Completing a self-check when limbic responses occur can help. Set up time weekly, or daily or use the 2-2-6 model – whatever works. Go through a BETR check for yourself. See if anything is staying with you. Dr. Black calls these, “sticky bits”. If anything is sticking after your first check. Check again after some time, and seek assistance from peers or supervisors.

Making regular time for a clinician’s mental health is vital to providing care for more uniform professionals (as well as other clients). Prioritize the helper as you suggest the helper prioritize themself!

BONUS

11. BETR Model

Finally, a bonus learned the skill from Wounded Warriors, the BETR Model. I have mentioned throughout this list the BETR Model which is a creation of Wounded Warriors Canada in conjunction with Dr. Black and his team. The BETR Model creates a framework that clients can use to assess their well-being. It stands for:

1. Body – the body is prime, if our basic needs aren’t met we can’t function, “no one can think themselves full” (Dr. Black, 2022)
2. Emotions – not quite as impactful as the body but everyone has them whether or not they choose to express them
3. Thoughts – as we get older, thoughts start to take precedence, and that last through to adulthood. Thoughts are difficult to handle, complex but still not as fundamental as emotions.
4. Relationships – these are the most complex aspects of human life as they take two or more people who all have Bodies, Emotions and Thoughts going into the Relationship

By beginning with the body we re-emphasize the base building block that it is (think about Maslow’s Hierarchy of Needs). Grounding exercises help to create a firm foundation and allow individuals to work up through the layers from there to emotions and thoughts. When completing a check, the idea is to just observe not change or fix. As you move to emotions identifying what one is feeling can sometimes be challenging. Help the client to identify and name their emotions – that can be therapy in itself. Then move the check to thoughts. Once again we’re observing only, encourage the client not to try and change anything.

If you find it difficult to teach your client, try some mindfulness exercises or suggest mindfulness apps that can help them. A word of caution is that sometimes individuals who have trauma in their past can find mindfulness difficult. Focusing on mindfulness activities that focus on the body often reduces this risk. If possible, have at least one exercise that works to help ground the client that they can use should they find themselves outside their window of tolerance.

These ideas are often a great place to start. Before any “deep work” commences, having the ability to recognize when one is outside their Window of Tolerance or hyper or hypo aroused is a safety requirement. Provide your clients with grounding techniques and teach them when to use them.

Closing Words

This summary of the 10 Most Important Things I Learned from Wounded Warriors Canada is just a snapshot. If you found the information helpful you can find their offerings here. The opinions expressed are mine alone and I do not have any connection or affiliation with Wounded Warriors Canada. If you have any questions or comments please feel free to contact me.

For more information about the Author please click here.