Why Graded Exposure Is Essential to Trauma Informed Pelvic Health with Lara Desrosiers

Mentioned in this podcast:

• The first ever Trauma-Informed Pelvic Health Certification by Lindsey + Lara
• OT Pioneers: Intro to Pelvic Floor Therapy opens Sept 11-15, 2023

What we talk about in this episode:

• Graded exposure vs graded activity - what is the difference?
• Why Graded Exposure is a critical component in trauma informed care
• How we can give clients new tools to Manage distress in new ways
• Why it's important for graded exposure to be  led by the individual
• The importance of survival reactions + our adaptations
• Sensory aspects of our nervous system
• Is it possible to avoid triggering our clients? 
• What are key reflective processes in graded exposure?

Meet Lara Desrosiers, my guest and co creator of the first ever Trauma-Informed Pelvic Health Certification 
Lara is an Occupational Therapist in Ontario, Canada that has a private practice, Pelvic Resilience, dedicated to helping individuals struggling with pain and pelvic health challenges to get back to living life.  Lara has also leveraged her 10+ years of experience working in community mental health to mentor clinicians and teach courses designed to help practitioners from a variety of disciplines and settings to build more psychologically-informed and trauma-informed practices.

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Transcript

Lindsey Vestal My guest today is the amazing Lara Desrosiers of who I am collaborating with to create the first ever trauma informed Pelvic health certification. Can you believe we don't have one yet? Yes, the time is now. I think we are going to look back and realize this was so incredibly essential and it actually actually should be. Pelvic floor 1 to 1. It should be the course we all start off with and our journey and becoming a pelvic floor therapist. It's kicking off January through May of 2024. And there's a link in the show notes where you can learn more about this inaugural certification. First, only tell you a little bit more about Lara. She's an O.T. in Ontario, Canada. She's got a private practice with an incredible name, which is pelvic resilience. And she's dedicated to helping individuals struggling with pain and pelvic health challenges To get back to living life. Lara has leveraged her over a decade of experience working in community mental health to mentor clinicians and teach courses designed to help practitioners from a variety of disciplines and settings to build more psychologically informed and trauma informed practices. Lara is an absolute joy. I gained so much inspiration and wisdom every time her and I connect. I can't wait to share this episode with you. 

Intro New and seasoned OTs are finding their calling in Pelvic health after all, what's more ADL than sex, peeing and poop? But here's the question What does it take to become a successful, fulfilled and thriving OT in Pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions and this podcast will give you the answers. We are inspired, OTs. We are out of the box, OTs. We are Pelvic health OTs. I'm your host, Lindsey Vestal, and welcome to the OTs and Pelvic health Podcast. 

Lindsey Vestal Lara, I am thrilled you're here. I'm thrilled to be having this conversation with you. I know that great exposure is a topic that some of us may be less familiar with than others. I'm sure we've heard it discussed in maybe in school or in a continuing education class. But I really want to focus our conversation today very specifically on using graded exposure to facilitate trauma informed care. And, of course, you and I are working really collaboratively together to develop the first Pelvic health trauma informed certification. And so this is extra exciting to me to have you on as a guest today to discuss this. Thank you for being here. 

Lara Desrosiers Thank you for having me. Of course, I always enjoy chatting with you, Lindsey. But this topic. Yes in particular I get really excited about. I know for me, graded exposure is a tool that helps me feel really empowered to provide care for my clients, that helps them to connect with their body in new ways. And I just think of it as such a critical component of trauma informed care. 

Lindsey Vestal So I want to talk about the differences between graded exposure and graded activity. So we can start there. But I guess I'm also wondering if we could just start with defining graded exposure or maybe it's easier to to contrast the two, however you want to answer that question. I think it'd be lovely to kind of start off with just like a baseline understanding of this concept, right? 

Lara Desrosiers Yeah. And oftentimes I hear clinicians using them interchangeably. But there are some really critical differences between the two. And OTs can use. Absolutely use both. And sometimes we can do really solid graded activity with a graded exposure to it. And so the key differences is when we're talking about graded activity, what we're really talking about is gradually building up a client's capacity to do something. And so it might be building up strength, it might be building up endurance, it might be building up their capacity to downregulate. And so when we're looking at public health, it might be gradually through have activities that the therapist typically grades for and with the client building up their bodies capacity to do those things. And so it's often very prescriptive. The therapist is very actively involved in choosing the activities to help the client achieve that capacity, whether it's more strength, whether it's more flexibility, whatever it may be. But when we're talking about graded exposure, what we're targeting is distress. What we're targeting is the emotional reaction that someone might have to a certain activity, to a certain stimulus, to a certain trigger of some kind. And so what we're working on in graded exposure is supporting folks. We're managing that distress in new ways so that they can engage in the things that are important to them so that they can keep moving forward with their goals. But they've got more tools to manage the distress that might come up. So whether that's anxiety, whether that's frustration, whether that's a sense of helplessness. And a key difference with the graded exposure process is that it really needs to be led by the individual. They really need to be given a lot of choice, a lot of options. But really, it's it's them it's their emotional reaction. So they need to be choosing their readiness to move through that process and identify which activities will ramp up that stress or challenge them in a way that feels accessible to them without pushing their distress too high. So it really needs to be this much more collaborative and client led process. 

Lindsey Vestal I love that because already, even just with this overview, we're not getting to specifically set about trauma. That'll be my next question. But just this beautiful overview, Lara, It's really demonstrating how the graded exposure method is already empowering the client from day one. And that transfer into life outside of the session with you is they're already practicing that, right? Which which is what we want. We want that these skills to be transferable and for them to apply it to areas outside of pelvic floor therapy. Perhaps it's, you know, an intense encounter with a coworker, a meltdown with a child, you know, a heated moment with a partner, all of the ability to to tap back into the skill set that you're empowering them with, you know, definitely carries over to ADLs. So. Wow, this is amazing. 

Lara Desrosiers Yeah. Yeah. I think it's so critical and having kind of a working understanding of the process and how to carry out great exposure with folks effectively can add such an empowering layer to the, to the public health work we're doing. 

Lindsey Vestal Just so I'll, I'll be direct then and let's link this to two Pelvic health. Why is rated exposure an essential component for trauma informed? Pelvic health? 

Lara Desrosiers Yeah, I think that's it's such a good question. And the reason I think that it's, it's so important and so useful is because a lot of what we're doing in pelvic floor therapy has the potential to be that stimulus or trigger that is really overwhelming to the client when we have encountered a highly stressful is that so whether someone explicitly identifies as someone who has a trauma history or or doesn't our nervous system still develop these survival reactions? Right. And these survival reactions typically happen typically can leave our nervous system. I would say at a place that's often really hyper vigilant to stimuli that might have remind it might remind our bodies of that highly stressful event, even if it's not really explicitly connected. It's typically the sensory aspects of the experience that can really kind of trigger those responses and kind of overwhelm in the nervous system. And so our nervous system is so adaptive, and what it tends to do, what we tend to do as humans, is develop these survival coping strategies where we're we're kind of we can avoid or try and disconnect from those stimuli that might be really triggering to us. And so for folks who have experienced trauma, oftentimes that's disconnecting from the body, right? There's can be a lot of sensations that might really ramp up those responses. And and lots of folks with a trauma history build this capacity to really disconnect from that to protect themselves. It's a self preservation thing with the breath disconnect from or automatically we we can hold our body in different kind of protective positions. And if we think about what we do in public health, what are we on that first session? Oftentimes asking folks to tune into the sensations in their body, their breath. We're asking them to tune in to their alignment and how they're holding their body. And so being able to recognize that sometimes folks have developed patterns based on these survival mechanisms, it can help us kind of understand that sometimes we need to do these things in a really great way with folks instead of flooding them with some things that have the potential to be overwhelming all at once. And oftentimes I think the pattern can be or the assumption can be that when we're talking about trauma informed public health, the goal is to try and avoid overwhelming or triggering our clients. But I think the reality is, is that when we're doing and talking about these really sensitive things with folks, avoiding that overwhelm altogether might not necessarily be possible. So we really need to build our skills with. Being able to recognize when that overwhelm is happening and then work collaboratively with our clients to progress them in a graded way at it at a pace that works for them. It can be really tempting if you don't feel like you have the skills to to engage folks in this process. To abandon ship on that activity, if it's too overwhelming or kind of take a step back, which which can keep them stuck in their frustrating pelvic health symptoms. Right? They might really be wanting to move forward. So greater exposure to me really gives us those tools where we can keep moving forward, empower our clients to kind of recognize their bodily signs of distress. They're more conscious signs of distress and work through pelvic floor therapy at a pace that works for them. That was a long winded answer. 

Lindsey Vestal And it was it was gave me so much to think about. And one of the things that really pops out to me is, you know, this is a podcast for professionals, for people who practice in Pelvic health. And one of the things that I also hear you saying in this in this wonderful definition about graded exposure is that as clinicians, we need to remind ourselves that healing is not always a straightforward journey, nor is our approach. So it's not there's no playbook, you know, there's no guidebook that you're going to need to be able to give me or that I can give you that says, you know, practice graded exposure in this way in this order for every client. And that can be intimidating when we're first starting off. It ends up being very liberating and very interesting the longer we practice. But what I want to call out specifically is the grace that I want everyone listening to this podcast to give themselves because because we know healing is not a straight linear path. Sometimes we're going to try something for the client that maybe isn't working or that does ramp up their nervous system. And so it's that attunement and that co regulation that we might work with doesn't form us. But we're not always going to get it right 100% of the time. So just like our clients are learning that, I also want to remind us as practitioners and clinicians to remind ourselves that that it's this is a work in progress, that we're human beings and that that messy middle with as long as we approach it with integrity and always coming back to that goal that we're trying to help our clients on their healing journey as that facilitator or we're not always going to get it right. 

Lara Desrosiers Yeah. And I think that's one of the beautiful things about graded exposure and it being that more collaborative process, right? It's when we encounter kind of an obstacle at the trajectory that we're going. A key component of graded exposure is the reflection process, like taking the experience and processing it together. And so it takes the pressure off of our shoulders because when we encounter that moment where maybe things aren't going to plan or the client's having a reaction to one of the indirect interventions that we're trying, if we process that with them, it becomes an opportunity to grow even further, right? We can figure out what about that maybe created that reaction and together, how can we adapt this or maybe pivot to something else or adapt this strategy to meet you better meet you where you are? So even I find it takes so much pressure off of me to feel like I need to have all the answers. And when I treat it more as that collaborative process. 

Lindsey Vestal That's truly client centered, isn't it? Right. 

Lara Desrosiers So it's been benefiting everybody. I love I love that this is. 

Lindsey Vestal This is this is awesome. I'd love to know what are some specific goals of graded exposure? What are we trying to accomplish? And Lara, really, how does it work? 

Lara Desrosiers Yeah. So depending on there are some great exposure has evolved so much over time and there are so many different models of graded exposure. I would say the traditional kind of cognitive behavioral therapy model of graded exposure, one of the key goals of of it was something called expectancy violation. And so that really has to do with looking at the client's beliefs and predictions about how an experimenter an activity is going to go. And what we're really looking for is then giving them the opportunity to test out those beliefs and have the opportunity to surprise their brains and say, you know what, I anticipated that I wasn't going to be able to get through that, but actually I was. And so that goal has more to do with kind of the working with the conscious brain right there, conscious awareness and predictions about their pain, their symptoms and how they're going to cope with that. Another goal and an outcome that we're often looking for with graded exposure is something called habituation. And habituation has more to do with the fact that when we encounter distress, it typically occurs in this wave, right, with this spike of distress, and then it gradually kind of settles down. And the theory is the more gradually and systematically that we're exposed to that. Stressing stimulus or trigger. That spike of anxiety doesn't go quite so high and the wave settles down a little bit more quickly. The more we start to break the connections that have built up over time between that stimulus and it being a threat, the more we have those experiences. I would say my biggest where I often get the biggest moments with clients and where I really like to focus the reflection process with them is around building self-efficacy, building this sense of agency that, yeah, there might be some pain or there might be some anxiety as I'm pushing myself outside of my comfort zone. And I often invite them to consider, well, how did you manage that when when it came up? And really the aim is to build that sense of agency with pushing themselves a little bit outside of that comfort zone. And I would say the fourth goal or another kind of component that I really try and work towards alongside my clients when we're using created exposure comes from putting an act twist and an acceptance and commitment therapy to ask for an acceptance and commitment therapy kind of lens on graded exposure and that psychological flexibility. So can we build up your capacity to be present curiously and compassionately present with the difficult things that come up when you encounter this new thing in service of continuing to take steps forward towards what's important to you and what's meaningful to you. So that involves really ensuring that when we're using graded exposure with folks, we're choosing goals that are really important and meaningful to them. And there's a huge mindfulness component to it as well. Can we support them with gradually being more present with maybe some of those internal sensations that that are scary for them? Yeah, I think at the core Foundation is the client having control and agency throughout the process. And so we really need to ensure that we're not being too directive. And that's, that's where we might kind of bounce back into the creative activity kind of bubble of what we're doing, but really ensuring that, that we're presenting clients with lots of options. I love the term of, of kind of presenting a menu to clients of these are some different ways we can support you with progressing and ensuring that they get to choose where we start. Another key component I think of graded exposure is that idea of mindfulness through the process and can we facilitate you being fully present? And so one of the things that we'll well teach in our certification and that can be a really important kind of starting point for greatest exposure within trauma informed care is can we support our clients with having like to call them anchors. So something that can if they start to feel overwhelmed, a sensory experience that can really help to anchor them back to the present moment. And so I often like to explore that a little bit with my clients before launching into an activity that has the potential to put them into distress or graded exposure process. I think starting with teasing out how to resource them with those anchors so that they can see through the processes is really critical. I think another key feature that I always talk to folks about is self-care. If we are agreeing that you're at a place where you're wanting to kind of challenge yourself and push yourself outside of your comfort zone, we know that this is going to be tough. We know this is going to be draining for you. So let's put some planning in place around when you're going to do this, how you're going to take care of yourself afterwards so that we can optimize the chances of success. I also like to have that conversation around even if things don't go to plan. We can take away some great learnings from that. So let's come back and talk about it and so that clients aren't going away and feeling sometimes there's that, that temptation to get into that black and white mindset of this isn't working and shutting it down, but come back and let's talk about it and making sure they know that I'm their partner in this, right? That we can kind of navigate any obstacles that might come up that maybe we didn't think to plan for ahead of time. And then with graded exposure, really, we're bringing in that component and checking in on their distress and their emotions and how they're feeling through the process versus just focusing on the physical pieces. And so there's a really key reflection process where really wanting to be that container and hold space afterwards to help them pull together the pieces of the experience, integrate new experience into their belief system, into their relationship with their body. We really want to give them the space to make that experience a meaningful one in their process. 

Lindsey Vestal That sounds incredible. I think this sounds like the foundation of pelvic floor therapy in general, specifically trauma informed. But I think that, you know, the gold standard is what do we do in the United States? What do we do? We get it on the table and we do an internal exam. And of course, there's a bit rapport building. There's some conversation that happens beforehand. But hearing Lara, you talk about these these key features, it really reminds me why that is such an antiquated version, antiquated definition of expectations for that first day. And this has nothing to do with whether we know there's a trauma or not. Let's be honest. Pelvic floor therapy is intense. It's vulnerable. It's the most intimate part of our body that potentially we haven't shared with very many people before. And we're coming in usually with a problem with something happening. And so there's even more a sense that can often accompany of shame and disregard and really a sense of just kind of feeling like, am I going to get through this? And so all of these key features that you explain, you can really see how they have that quilt quilted pattern or that that that layer that needs to be there so that it's there. It's threaded throughout all of the experiences and conversations, regardless of if that internal exam is necessary and regardless of it happens, you can really see how these anchors are really, quite honestly, prerequisites for entering in any pelvic floor therapy experience. Yeah. 

Lara Desrosiers Yeah, absolutely. And I think you hit the nail on the head, too, with the idea that this applies whether someone has an explicit trauma history that they're there disclosing to you or not. And so the example that comes front of mind to me is vaginismus. And I've worked with clients who have shared an explicit trauma history with me. And then I've also worked with clients with Vaginismus who don't identify as having a trauma history. But there's still something about certain certain activities and pelvic floor therapy and certain activities related to their sexual health and their sexual functioning that their body is reacting to. Right. That's their body is resisting, too. And so we still need to find ways to listen to the body and and understand that the body is there's some sort of sign of threat there that the body is reacting to. And these principles are still so useful. We still need to put the person in the driver's seat to choose where they are comfortable starting in terms of connecting to their pelvic floor in different ways, whether they choose visual strategies, sensory or tactile strategies, whether they choose instruments or your finger. Like we really need to be given everyone's choice, whether they're coming with explicitly disclosing a trauma history or not. 

Lindsey Vestal I couldn't agree more. Or do you have like a an example or a case study that might kind of stitch all this together in a very tangible way? 

Lara Desrosiers Yeah, vaginismus is a big one. I think where this is really applicable and we can look at really helping folks to understand their pelvic floor muscle reactions within the context of their body, showing signs of reacting to a threat. Right. And building instead of just kind of passively doing that dilator work to try and stretch the tissues. Incorporating some of the cognitive pieces, some of the sensory pieces and building ins, leaving in some of the greatest exposure to help them take a more holistic approach to navigating the threat that their body is detecting. Another example that often comes to mind is one of my passions is pelvic working prolapse. And so a lot of clients that I've worked with with pelvic or in prolapse have come with an explicit birth trauma story that maybe there is instrumentation involved in their. In their childbirth. But there's there's an element of that birth trauma involved in their journey and. Many of my clients with pop who have this birth trauma history identify that their pops symptoms, the pop sensations themselves can be a massive trigger, a massive trigger in terms of pulling them back into their body, back into that traumatic experience, that feeling of not having any control, of not having an agency. And so taking a graded exposure approach to how they navigate and manage and interpret when those symptoms flare up and can be really useful in prolapse as well. And so when I take a greater exposure approach, when that's the primary issue for a client, it oftentimes involves really dipping our toe into some mindfulness strategies, tuning into the body, but not going to let asking them to go away and do a 20 minute body scan right outside, but really working with them to figure out how can we resource you to tune into these sensations in a more curious and compassionate way? And let's play with doing that in a very gradual and systematic way. So might be body checking to start or just getting from them. What are those moments where those sensations kind of pull you and then hook you then? And then can we empower you to encounter that with more tools? I love that. 

Lindsey Vestal Those are two excellent examples and I think two definite pelvic health diagnoses that we see that absolutely, absolutely require this much body, mind centering approach. So thank you. Thank you for that. I am really excited that in January through May of 2024, you and I will be partnering to work on our Pelvic health Trauma Informed Certification. I'll include all the information in the show notes for anyone who would like to be a part of that journey with us. It, to me, were to look back on this. Lara, I don't know, three, five years, maybe less, and think, how was this not in place sooner? Why were these not conversations that we were having? And I really want to thank you for your time today because I think all of this great exposure conversation really illustrates how this is fundamental human care. This is a fundamental approach towards anyone in Pelvic health. And so thank you for for leading the way on all of this. 

Lara Desrosiers It's my pleasure. Thank you for having me. Lindsey And I think a thought that's coming to mind that I'd love to just share before we log off is I'm really passionate about this certification because I think I've seen I've seen and heard and worked with a lot of public health clinicians where we're defining trauma informed public health as the avoidance of triggering our clients. But we really need to I think I'm really passionate about empowering clinicians to have more tools so that it's not just about the avoidance and more about building that confidence to continue to work with our clients and support them with moving towards their goals. And I really think great exposure is a wonderful vehicle for doing that with folks. 

Lindsey Vestal Thank you, Lara. 

Lara Desrosiers My pleasure. Thank you. Lindsey. 

Lindsey Vestal If you are interested in making history and being a part of the inaugural group for the first ever trauma informed Pelvic health certification, check out the link in the show notes to learn more. It's kicking off January through May 20th, 24, and Lara and I would be honored to support you. 

Outro Thanks for listening to another episode of OTs and Pelvic health. If you haven't already, hop on to Facebook and join my group OTs for Pelvic health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and posted to IG Facebook or wherever you post your stuff and be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic health podcast.