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Posts Tagged ‘mental health’


The Second Pandemic: PTSD

Posted on: by Susan

 

It has been a little over one year since COVID 19 made its world debut. In that time we have all seen reports of horrendous deaths from the disease, the toll it has taken on our healthcare professionals and the tremendous changes it has brought to every society in the world:

  • constant mask wearing
  • hypervigilance around health and contagion
  • decreased movement around our communities and world
  • elimination of cultural group activities from rock concerts to political events to pubs
  • the constant background fear of death or long term disability

In addition to these profoundly stressful changes in our lives, we have seen brutal killings on live TV by people who are supposed to protect us, as well as by mass murderers; social and political uprisings, the polarization of politics and the death of cooperation between political parties. These changes have left people all over the world uncertain about their future, about their safety, and about their financial survival. 

Many people understand that they are chronically traumatized. And many deny that these events affect them, even while acting out their fears and angers on their loved ones and those around them (itself a trauma symptom).

In the current Diagnostics and Statistical Manual on PTSD we have a list of criteria that apply to our collective experience of COVID and mass unrest. I have paraphrased some of these criteria; the ones that are verbatim from the DSM are in quotes.

1. “Exposure to actual or threatened death” by one of these four means: “directly experience the traumatic event(s)”, “witnessing in person, the traumatic event(s) as it occurred to to others, “learning that the traumatic event(s) occurred to a close family member or friend, and/or experiencing repeated or “extreme exposure to aversive details about the event(s)” as part of one’s work. 

Check. We would have to be very isolated indeed to not have experienced at least one of these criteria. As for the fourth criteria, that is officially listed as being “part of one’s work”, I disagree as a trauma therapist. Exposure is exposure. Just because the DSM says your exposure doesn’t count because you were not ‘on the job’ doesn’t mean that you were not traumatized. There is research showing that repeated viewings of traumas on TV or other media create a trauma response in viewers. I believe this criteria may be changed in future versions of the DSM.

2. Presence of one or more of these disturbing intrusive symptoms: uncontrollable recurrent memories and perseverations around the event(s); nightmares related to either the content of the event or the emotions around the event (loss, sickness, contagion, fear of the future etc.); flashbacks, or other dissociative reactions around the event(s), which for children can include repetitive play of the trauma or event; “intense or prolonged psychological distress at exposure to internal [your own memories] or external [in the environment] that symbolize or resemble an aspect of the traumatic event.

Translation: You cannot stop thinking about COVID, COVID related losses (school, travel, etc.) or other traumatic events related to COVID or social unrest. You cannot stop the feels that keep coming, and you feel depleted because of this. It is hard to focus on daily routines and feel ‘normal’ again. You may take extraordinary precautions that are not strictly necessary or none at all as a rebellion to these feelings.  You may have insomnia as the mind unconsciously avoids dream content related to COVID or social unrest and pops us out of sleep as we approach REM phase, where memories are processed.

3. Avoiding anything that reminds you of the traumatic event(s) in one or two of these ways: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about  or closely associated with the traumatic event(s) and/or “ [making] efforts to avoid external reminders (people, places, conversations,  activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)”. 

In other words, you don’t want to think about it and you don’t want to talk about it anymore. Even reading this blog may be a trigger. (Did you make it this far?) You may avoid shows about: illness, contagion, disasters etc. that you previously enjoyed. Or you may avoid discussing COVID with friends and family, or avoid talking about your feelings about it. Denial is another way our minds practice PTSD-related  avoidance. We may minimize COVID or say we are not at risk, or refuse to take precautionary measures. All of these are trauma responses, in other words,  our mind unconsciously and automatically protects us through avoidance.

Some of these behaviors make other people very angry and are themselves a stimulation of the trauma. You may be very reactive to people who minimize the risk of COVID to themselves and others. Both of these reactions are traumatic in nature. We do not, necessarily, choose our defense (which is a whole other blog topic). Some people intellectualize and want to learn everything about the event; others want to know nothing or deny reality. Both groups are avoiding their feelings, although intellectualization is preferable to denial. Avoiding feelings, in general, is a traumatic response, as well as a cultural one (some cultures value feelings more than others). 

4.  Negative alterations in cognitions and mood associated with the traumatic event(s), as evidenced by two (or  more) of the following: 

  • Loss of memory around the event(s) [one of the more extreme reactions]
  • “Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world”
  • “Persistent, distorted cognitions about the cause or consequences of the traumatic  event(s) that lead the individual to blame himself/herself or others.”
  • “Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).”  
  • “ Markedly diminished interest or participation in significant activities.”  
  • “Feelings of detachment or estrangement from others.”  
  • “ Persistent inability to experience positive emotions (e.g., inability to experience  happiness, satisfaction, or loving feelings).” 

What strikes me about this section is how real it is socially, except for the loss of memory bit. 

(Also how much the word “persistent” is used.)

 “Persistent exaggerated negative beliefs or expectations about oneself, others or the world” Check.

“…lead the individual to blame himself/herself or others”

Check.

“Persistant negative emotional state”

Check. It’s like a nightmare we cannot get out of, which then becomes a trigger for all of our other unresolved traumas from this (and other, if you believe in that) lifetimes.

“Markedly diminished interest or participation in significant activities”. 

Check. But in a weird way. COVID prevents us from participation and maintaining interest. Double check.

“Persistent inability to experience positive emotions”. 

Check and Checkmate. We all feel depressed. We are all grieving. It is hard enough to maintain hope in the persistence of COVID, never mind the persistence of our collective trauma around COVID. Ugh.

5. Unpleasant behavioral changes as a result of the event that include two or more of the following: Insomnia or other sleep disturbance, inappropriate emotional outbursts that are out of character, hypervigilance, exaggerated startle response, and/or difficulty focusing and/or concentrating. 

Well, yes. Most of these for most folks. One only has to venture online to see the reactivity happening. Nearly everyone I know either as a friend or patient has struggled with sleep this year. You can check in with yourself as to whether you are still washing your hands 10 times/day or wearing your mask when you really do not need to (hypervigilance), or if you jump when someone comes up behind you unexpectedly. 

Many people came into this period of time with PTSD, either diagnosed or not. They have been suffering tremendously because their systems were already sensitive to traumatic stress. The rest of humanity may now suffer some level of PTSD. I say “level” because although PTSD is by definition a very unpleasant condition, it can have levels of severity beyond baseline. If you are having dissociative symptoms such as depersonalization (“feeling as though one were in a dream; feeling a sense of unreality of self or body  or of time moving slowly”)  or derealization (the world around you feels “unreal, dreamlike, distant,  or distorted”) you may have a more severe situation that needs attention. Technically it is called PTSD with dissociative symptoms. 

Oh yes. And these symptoms need to have gone on for more than one month. 

Check.

Please, dear reader, remember: I would not write this blog if I did not feel you or your loved ones could be helped. There are many resources available to help you heal from PTSD. My book, The Trauma Tool Kit: Healing PTSD From the Inside Out is available in libraries all over the world, and has a rating of 4.6/5 stars on Amazon where it is available on Kindle and Audible (in my own voice).

Be well and stay safe, Susan PB

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5 E-Kindle Book 5th Edition (p. 308). Indephent. Kindle Edition. 



Timelines and Trigger Mapping in Healing PTSD

Posted on: by Susan

In the “old” days of psychotherapy, when I began in the 80s, abreaction or emotional release of traumatic memories was considered a goal of therapy. This idea of therapy was also made popular in powerful movies such as Goodwill Hunting.

Abreaction will happen when it happens, and it will facilitate healing. But it is not enough.

We have to live with the day-to-day realities of our history as they manifest in the present moment. With that in mind, I wanted to share two of the most helpful activities in or out of therapy for people who suffer PTSD.

The first activity is to create a timeline of events. When our PTSD results in dissociation our sense of time can get distorted. In fact, many would say that PTSD itself distorts the part of the brain responsible for the sense of time passing.

In any case, most people I see have a very poor sense of the timeline of what happened to them. Also most people I see have had more than one type of trauma. Some peoples’ lives have been one traumatic event after another. Creating a visual timeline can help us understand and digest what we have actually been through.

 Chances are, when you begin, you will not put down every event. Our brains are associative, so if you are looking at, say, accidents, you will put down accidents. But, you may forget about abuse, or you may remember one type of abuse but not another. I consider the timeline a working document in therapy, whether on paper, or just as an understanding between my client and myself.

When you record an event, you have an opportunity to look at your age at the time. A good timeline should include: event, type of event, age and any other relevant details (such as physical injury).   The timeline provides a chance to re-associate the aspects of yourself connected to your own history and is a valuable tool for your therapist. (P.S. therapists can and do become dissociative too, so this tool can help ground both of you.)

The second important activity that will really start to empower you is trigger mapping. Everyone with PTSD has triggers! They may or may not be known to you. Knowing triggers can help you and your loved ones anticipate PTSD storms and head them off.

Here is how I describe trigger mapping in my book The Trauma Tool Kit:

I recommend writing down or drawing your triggers, getting them down on paper in some form or fashion. Some triggers you will know right away; some you will have to ferret out. Triggers fall into six categories: the five senses of taste, touch, smell, sight, and hearing, plus feeling states. Let’s start with the senses, because they are the easiest. You can divide your paper into different sections reflecting each of these senses. It will help jog your memory to go through each sense modality individually. Let’s say you are working in the smell category. Ask yourself what smells really bother you. All of us have smells we do and don’t like. Generally we all like floral scents and dislike the smell of feces, but I am not talking about ordinary aversions here; I am talking about radical reactions. Nobody likes the smell of poop, but if that smell sends you into a panic or frozen numbness and dissociation, it’s a trigger. Or maybe the scent of lavender makes you want to rip someone’s head off. That’s a little unusual; write it down. Take your time working through each category. Do not attempt to do all of this work in one day! If you are in therapy, it can feel safe and reassuring to do it with your therapist. Or it may not depending again on your triggers, but find some way to do it anyway. p. 184-185

The great thing about timelines and trigger mapping is that they create a bridge of healing between the present and the past. They empower and they inform, and they are tangible.  You can also add to them and edit them as you go. It is a great joy to be able to remove a trigger off the list!

One last thing, when you do them, do them with care and beauty. Take your time. Use beautiful colors and paper. Or if you just do them in your own head give yourself the benefit of a peaceful space and time to contemplate your own history and healing.

Blessings on your journey, Sue PB



Gun Control vs Mental Health: How Do We Stop the Killing?

Posted on: by Susan

Are mass murderers mentally ill or should we pursue gun control? This is a hot topic of debate. As a person who has a career spanning 40 years in mental health I would like to answer this question by answering some common statements that I’ve seen in the news the last few days.

“We don’t need gun control, we need better mental health services”. Wrong. We need both. If we have even one dangerously murderous potential mass murderer in our community we need to restrict their access to weapons. Isn’t this obvious, Republican Party?

“Most killers are not mentally ill.” What?! First of all I’d like to see a shred of statistical evidence to back that up. This is always said in forums with no citations. Even if there were stats for this amazing statement, can we consider where the known killers are? They are in prisons, American prisons, that famously do not provide adequate mental health services to inmates. No services equal no diagnoses, and no diagnoses equal no statistics. In the 1980s I did some research about serial killers (different than mass murderers but still…) and I found that an alarming number had temporal lobe lesions and/or diagnoses of Multiple Personality Disorder (what would now be Dissociative Identity Disorder).   We do not know jack daw about mass murderers. Most kill themselves, the rest end up in prison undertreated and definitely unresearched. As a therapist, when I read the descriptions of these folks they seem easily diagnosable to me. They are definitely not pinnacles of mental health and well being.

“Most mentally ill people do not kill other people.” Yes, that is a true statement. But that is not a reversible statement. See above. It is not logical to use this statement to establish anything. Even if mentally ill people don’t kill, they still deserve treatment. Most of us who have PTSD, for example, know that if a gun were in our hands in the wrong moment we could have killed ourselves or somebody else.  I believe a lot of couple murder/suicides happen this way, as terrible accidents that could have been prevented by not having a gun in the house.

“These people are not mentally ill, they are evil.” Really, folks it is 2015 not 1515. Should we sprinkle holy water on them? All sarcasm aside, to make this statement you have to assume that people are either born evil or choose to become evil. I do not subscribe to the belief that any human is born evil. Evil is a construct. Nobody is all good or all evil.   We are born babies, open to both good and evil actions . If a human grows up and identifies as evil, in other words, service to self above all others no matter what the cost they can wreak great havoc in the world. But if they are sanely evil, they do not usually end up dead, at least not for a while, they usually end up running corporations or governments (jk) (not really). Most of these mass murderers are young men who have barely started to live, and most end up dead at the end of their rampage. Where is the sanity in that? Calling these guys evil is lazy and glib and blinds us to solutions.

I recommend we all step back, take a deep breath and acknowledge to ourselves that each mass murderer is an individual with their own reasons for doing what they did. If we hope to prevent more such actions we need to seek to understand their behaviors and address the disconnection and untreated suffering that led to such a horrible event. And we need gun control.

 



Health Care Providers: How to Welcome and Respond to Trauma Disclosure

Posted on: by Susan

TMIMy husband, a cardiologist, and I recently spoke to a group of physicians about how heart disease is caused by traumatic stress and also causes it. Afterwards, one family practice doc asked me, “I never know what to say when patients tell me their traumas.”

I realized that many doctors and therapists, for that matter, were trained in an era before abuse was acknowledged, before trauma and PTSD were common household words (in some places they still are not).

So I’ve compiled a short list of do’s and don’t’s when answering a client that discloses a disturbing history of trauma or a traumatic event.

Do:

~ Routinely administer a screening questionnaire for abuse in your intake forms. You can use the ACE questionnaire or website or come up with your own boxes to check off (e.g. history of physical abuse, sexual abuse, domestic violence, neglect, veteran etc.) Clients with a very high ACEs score will have more health problems as they age.

~ Answer with a sympathetic and simple affirming response such as:

“I’m sorry that happened to you.”
“ That is a terrible thing to have to go through.”
“You must really be suffering a lot (if the event is currently affecting the client).”

If your client’s disclosure is met with a stony or panicked silence they will leave feeling very guilty, damaged, enraged or all three. Abuse has a lot of shame associated with it. Please do not reinforce this by failing to respond appropriately.

~ Maintain eye contact with a soft gaze. Our clients often do not feel seen or like others really want to see them and their suffering. Eyes are “the windows of the soul” and the client really needs to see that you are with them in taking this great risk of disclosure. We know that people are present to us and with us when they look into our eyes.

~ Get yourself grounded in that moment. Take a deep breath and take a moment to really absorb what your client just said to you.

Some of us providers have our own trauma histories and the older we are the more likely that is. If we dissociate or ‘check out’ our client will definitely notice and probably assign the worst possible meaning to our behavior such as: “they don’t really care about me”; “they are just collecting their paycheck”; “they think I’m crazy”. Our traumatized clients already have those feelings, and they respond to any perceived confirmation of those thoughts with panic and/or rage. This panic/rage can be expressed outwardly in your office as difficult behavior or as self-harm when they go home.

~ Ask for more details – especially about how this is affecting the patient in their body right now. It is a universal truth that our clients will only tell us what we are ready to hear. They do not want to ‘injure’ us with sordid details and will often leave out important aspects of their traumas. Occasionally a client will disclose too much in a kind of verbal diarrhea manner; in those cases it is OK to gently contain the discussion and take the necessary action for that client to get help.

~ Assess for current safety and contact the correct agencies as a mandated reporter. You can never overreport elder abuse or child abuse. As a medical social work supervisor I am always surprised about how conflicted medical staff are about filing reports and how little the laws are understood and followed. The state is responsible for determining whether abuse is happening or not. Most medical providers are not trained to make those screening decisions. Hence the law that says you are a mandated reporter to file if abuse is suspected. And, yes, that means everyone on your team who has a contact with the patient. It is extremely common for abuse victims to divide up what they tell to different people. There is no way for agencies to file as a single entity. If a doctor, a nurse and a social worker talk to this person and get any kind of disclosure they ALL are legally obligated to file a report. Our clients almost never call disclosure hotlines themselves. Sometimes they don’t understand that what is happening is reportable. Child and adult lives depend on us doing our jobs. The states do a very good job of maintaining confidentiality about who said what.

~ Refer! to the appropriate provider. Have a list of trusted mental health providers in your office. Steer your client towards the Psychology Today referral website which is excellent and widely used by practitioners.

Do Not:

~ Panic. Forewarned is forearmed. Educate yourself about the types of abuse in your community and the populations you serve. If you are expecting to hear these types of disclosures (and why shouldn’t you?) your clients will have an easier time telling and you will have an easier time hearing. I have heard about some truly horrendous and damaging responses from both therapists and doctors who were not ready to hear an abuse disclosure. One damaging response can put off a patient’s healing for years or forever.

~ Promise to keep a dangerous secret. A lot of patients will ask us to keep what they tell us confidential before they want to disclose anything. Don’t paint yourself into a corner. When my patients ask me to keep their secrets, I always reply that it depends on what kind of secret they have and explain my role as a mandated reporter. That gives them more control on what they want to disclose.

~ Ignore a disclosure. Yes, I know you have less time to do more work than at any other time in your career. Working correctly with a disclosure does not have to take a great deal of time. Our patients are pretty savvy. They know we have busy schedules and lives, and they do too. The vast majority of people who disclose will not abuse the privilege. If they do, you can still be kind and containing at the same time. Or you can ask them to schedule a longer appointment soon for a full trauma assessment (something I hope to be coming soon to a medical and psychiatric clinic near you). Being busy is no excuse for being uncaring. It’s not business; it’s personal.

~ Forget to take care of yourself. Know your community population. If you are in low income, high crime area, your entire population may be filled with trauma. Taking a trauma informed approach to your practice could be the best thing you ever do for you and can avoid needless complaints and confrontations. Get therapy if you need it (and who doesn’t?). Do your own sympathetic downregulating exercises: yoga, tai chi, meditation, exercise, breathwork. The less you care for yourself and your own suffering, the less you will want to help anyone else.

There, that wasn’t so hard was it?! If you need more in-depth assistance I offer trauma-informed consultations for health care professionals, and I travel!

Be well!



Five Questions You Should Ask Your New Trauma Therapist

Posted on: by Susan

Let’s face it, most of us don’t get ourselves into therapy until we are so broken and desperate we can barely get ourselves to the office. We are in a state of extreme need and vulnerability (usually), and the last thing on our minds is interviewing our own therapist. We want answers, and we want help, and we want it now!!!

I understand; I have been there. That is why I am giving you a list you can bring with you to your first two or three sessions so that you can really make an informed decision about how well you and your therapist are a fit. If the first session, you are in total crisis, don’t worry! You can ask these questions any time. But the sooner, the better. It is awful to get into a therapy and then realize you don’t like this therapist, don’t find them helpful, or, even worse, that they don’t like or ‘get’ you.

Remember that your therapist is YOUR hire. You are paying them to render a service, and you are in charge. If you like or don’t like what they are doing, talk to them about it! Just like with hairdressers or massage therapists, monogamy is not required. It’s therapy, not marriage.

OK, then. Here are some excellent questions to ask:

1) What professional organization(s) do you belong to? A mature and successful professional will always want to be part of a professional group larger than themselves. Professional groups provide leadership, advocacy and ongoing education to their members. Really invested professional trauma therapists should belong to at least one professional trauma organization such as the International Society for the Study of Stress and Dissociation (ISSTD); the International Society for Traumatic Stress Studies (ISTSS); the American Professional Psychology Division 56 (Division of Trauma Psychology) or one of many others. Hopefully they also belong to their local professional chapter: for social workers NASW, for psychologists, APA, the AMA if they are a psychiatrist, and so on. If they rattle off a bunch of names and letters you do not understand that is probably a good sign. They all have websites. Feel free to check them out. Many of these organizations have their own lists of providers. If they are expert presenters for these organizations, even better!

2) Do you have any special certification or training in Trauma therapy?beautiful therapy Good answers:
Specialized supervision (regular meetings to review cases and learn from them) provided by an experienced trauma therapist or internships in trauma treatment centers. ISSTD and other organizations offer specialized courses and certifications. Also, the American Academy of Experts in Traumatic Stress certify practitioners in a number of traumatic specialty areas including crisis response, child, etc. based on their accomplishments and years of work in the field.

Bad answers:
No. Or I understand trauma because I had a lot of it. Or I’m a good therapist and good therapists can treat anything (run away).

Trauma therapy is an advanced practice specialty area that always requires special training to be good at. You wouldn’t go to a general family doctor for a heart attack, so don’t think that any therapist can do this work. They can’t and may do you more harm than good.

3) Do you understand and treat dissociative disorders?
A surprising number of therapists have never been taught to work with dissociative disorders, don’t recognize them when they see them, and can waste years of patients’ time (not to mention money) by this lack of understanding. Dissociative disorders and traumas go hand in hand. There is even a dissociative subtype for PTSD in the latest diagnostic manual (DSM 5). If you know you have lots of trauma, or lack a significant portion of childhood memories (dissociative amnesia) you have a higher likelihood of a false and unhelpful diagnosis if your therapist does not specialize in trauma and dissociation. Common misdiagnoses are bipolar disorder, borderline personality disorder and schizophrenia.

4) Have you completed your own course of therapy?
This is an awkward but TOTALLY FAIR question, one, quite frankly, that I wish more people would ask. In the good old days, in the heyday of amazing long term therapy, it was considered on the verge of malpractice and utter ignorance not to complete one’s own therapy before embarking on treating other people. Now it is rather the norm. Very few therapists I supervise have had much of their own treatment.

There is a misconception out there that therapists are sicker than the general population and become therapists to cure themselves. After 40 years in the field, I do not subscribe to this idea. Almost everyone in society has been exposed to trauma and mental illness in their families. Very few of those people want to understand it and go on to help others – those special few are therapists.

But being a psychotherapist working with traumatized people is an incredibly challenging calling. It’s easy to make mistakes, mostly unconscious or ignorant ones. So it is important that the therapist has had enough of their own therapy to understand how their own mind defends itself and operates unconsciously so that they can work well with other minds. This is a long and arduous task requiring many hours of training and work over a period of years.

So don’t be put off by a therapist who had a lengthy therapy themselves. Chances are good that somebody in therapy for 10 years will be a much better therapist than someone who went to treatment for six months and called it ‘good’.

5) Do you believe that people can have repressed memories of trauma that they recall later in their life?

There has been a big debate in the media about this, but in the world of professional trauma therapy the debate has been over for a while. The answer is “yes, of course”. Jennifer Freyd, cognitive psychologist at the University of Oregon, and editor of the ISSTD journal, did a great deal of work in the area of what she calls “betrayal trauma”, the trauma inflicted by a caregiver. She has showed in numerous studies that the closer the relationship of the abuser to the abused, the more likely the victim will have traumatic amnesia for the event.

If memories start to surface in your therapy, you will want to make sure that you will be believed and helped. It is extremely poor therapy to answer ‘no’ to this question, because that indicates the presence of dogma and a closed mind. You may have some very challenging and unusual things to tell your therapist, and you need to trust that they can hear those things and continue to work with you in a safe and containing way.

If you don’t feel like you can ask these questions in person, there is always email! Or go to your therapist’s website and investigate them deeply. You will save yourself some emotional distress and money by being proactive in your search for a truly helpful trauma therapist. Good luck!

Susan answers all of these questions in the affirmative and would be happy to answer more here!



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