Mastering Trauma Informed CBT Principles for Rapid Relief

Hey there everybody, and welcome to this presentation on trauma informed cognitive behavioral therapy. I'm your host, Dr. Donnellice Snipes. In this video, we're going to define trauma, explore the prevalence of trauma, identify the key elements of trauma informed care, and the principles of trauma informed care. We'll learn about the ongoing impact of trauma, discuss how trauma might contribute to the development of a variety of symptoms, and how to address them from a cognitive behavioral standpoint. Just because something does not meet the DSM criteria for acute stress disorder or post traumatic stress disorder does not mean it wasn't traumatic. And that's why a lot of clinicians have started embracing the term big T or for PTSD worthy triggers and little T for other traumas that don't rise to that level. But little T traumas are no less damaging for a lot of people than big T traumas. And the analogy I make is a rock. If you take a rock and you smack it with a hammer and you chip a piece off, that's like a big T trauma. It, it changes the rock significantly and it happens all of a sudden. Little T traumas are like taking a rock and putting it in a river where the water rushes over it and erodes it. Over time, does the rock change? Yes, at least as much, if not more than it did with that big T with that big hammer. But it's important to recognize and not minimize the impact that the erosion has on the rock. And CPTSD or little T traumas often have an eroding effect on people's lives, so we're going to talk more about that. But trauma itself is very simply something that overwhelms a person's capacity to cope, removes a sense of safety and empowerment, and affects the whole person physically. When people experience trauma, it triggers their stress response system, their HPA axis. And until they feel safe again, that HPA axis is going to stay activated. When the HPA axis is activated, it impairs immunity, it impairs sleep, it impairs a lot of biological functioning, it alters the gut microbiome. There's a whole host of ways that trauma impacts the person physically, emotionally. Trauma impacts how a person feels. They can feel guilty, they can feel terrified, they can feel depressed, they can feel angry, they can grieve, they can feel all of the above cognitively. After we experience a trauma, it impacts how we perceive others, how we perceive the world, it impacts our expectations. So it changes our cognitions and potentially our perceptions environmentally. After people experience trauma again, especially until they feel safe again, they may Feel unsafe in a lot more environments. Environmentally triggers sights, sounds, smells that are associated with the trauma are now going to trigger a traumatic memory. So the environment has changed and sets. Instead of being completely benign, now it is more fraught with potholes, so to speak. And relationally or interpersonally, trauma affects people. If it is a trauma that is induced by another person, then it may impact how people feel about others. It may impact how they feel about their ability to trust others. It may impact how they feel about their ability to trust their own judgment. If it is a natural disaster, for example, it may impact how people feel about others based on how they react in the aftermath of the trauma. Trauma can occur at any age or developmental stage. People may experience the traumatic event directly. They're there, they experience it, it happened to them. They may witness it, or they may even hear about an event that affects somebody that they know that's very close to them. When we hear about something that a loved one experienced, our empathy can sometimes put us into that situation with them mentally, so we can become equally or similarly traumatized. It's not just the event itself that determines whether something is traumatic, but the individual's experience of the event. People can experience traumas and not develop PTSD or cptsd. Traumatic injury refers to ongoing issues associated with the trauma. If people experience a trauma and receive sufficient support and love and are quickly returned to a place where they feel safe and empowered, that is going to be very different than if they didn't receive those things. What's the prevalence of trauma? 61% of men and 51% of women in the general population have experienced trauma. And I would say, well, I know that that is an older statistic. Over the past five years, they. There have been a lot of widespread traumas. So I would guess that the number is significantly higher than that. But we don't have data from 2020 and forward quite yet. 25% of school age children have experienced trauma, 96% of female offenders, so people who are incarcerated, 75 to 93% of youth in juvenile justice. Depending on which study you look at. 93% of homeless mothers and 83% of homeless children have experienced trauma, 93% of adolescents in psych hospitals and 75% of people in addictions treatment and 81 to 93% of veterans. Now you may be thinking to yourself for some of these, how can it be less than 100%? These. This data is compiled based on giving people surveys about whether they perceive that they have been exposed to trauma. So what is Traumatic for one person may not be perceived as traumatic for another person. So it is important to recognize that there's a lot of variability in the numbers about the prevalence of trauma. But even with these numbers where we're just taking people's self reported trauma, that is a lot. 83, 93%. Again, we recognize that a lot of people who experience trauma have the support they need to cope with it. So it doesn't lead to traumatic injury. But unfortunately I'm going to go out on a limb and say the majority of people that we see in mental health or behavioral health clinics and even in hospitals like physical Health hospitals may have not had that support and may have experienced traumatic injury. Key elements of trauma informed care Realizing the prevalence of trauma, recognizing how it affects individuals and putting this knowledge into practice. Traumatic experiences trigger the stress response or the HPA axis, which increases awareness and encoding of sensory input as well as physical sensations and thoughts into a memory. Van der Kolk often says that trauma is experience as a sensation, not as a memory in a lot of people. So some people may not have a full clear memory of what happened, but when they're exposed to particular triggers, they have this feeling in their body that causes them distress. We do want to recognize this, but it's also important to recognize that when people are experiencing trauma, when their HPA axis is activated, when they're under significant stress, their brain automatically becomes hyper aware of the people and the stimuli in the environment and it encodes all this stuff in order to protect itself. So the next time that it's exposed to any of those stimuli, it may trigger a trauma related response. And that is really important to remember. When all of these sensations and memories and anything else are encoded, it becomes what I'll call a memory. And that memory either forms a schema, maybe the person's never experienced anything like it before. So it's like, okay, when I ride on subways, the this is what I need to remember or is added to a schema. Now remember schemas are your brain shortcut. It's your brain's way of helping you anticipate what to expect. Stoplights is the schema that I usually use. If you've been driving for any point of time, in any length of time, you know that when you come to up to a stoplight, if it's yellow is going to turn red, you don't have to think about that. You have schema about stoplights. So if you pull up to a stoplight and it's yellow and then it turns green, or goes off completely. Then all of a sudden you're jarred out of your autopilot because that schema doesn't work anymore and you're having to engage your executive control network. Triggers, which can be in the form of sites, smells, sounds, sensations that are associated with that event, can activate the schema and associated perceptions, feelings, behaviors and cognitions, and it can be a relatively benign trigger. For example, someone who was in a car accident on the interstate may have encoded the smell of gasoline or the sound of ambulances in their trauma memory. So now whenever they hear an ambulance or smell gasoline, it triggers trauma responses in them. It may not be a full blown flashback, but they may get that sensation or perception of feeling unsafe. In terms of trauma informed cognitive behavioral therapy, it's vital that we recognize that many psychological cognitive behavioral symptoms originate from adapting to the traumatic experience. So we want to get curious about people's thoughts and experiences. These traumatic experiences influence how people respond to the environment, relationships, as well as interventions that we may propose and treatment services. If people feel remember, trauma strips away a person's sense of safety and empowerment. So if they come into counseling and we are too directive or they perceive that we're invalidating, then that is going to again put them in a position where they may feel unsafe and disempowered and cause them to reject treatment services or not respond well to interventions or not respond, as we expected, to interventions. Traumatic experiences also shape the assumptions that people make about their world. Whether they view others as trustworthy and safe or not, how they view the agency that you might work for or the system and their sense of safety in general. In the world, people, aside from do they feel like it's safe to leave their house, it shapes their assumptions about their future, whether they can have hope or not, or whether they fear or for a foreshortened future. And it shapes their assumptions about themselves, whether they're resilient and capable, whether they're lovable or competent in living their life and regulating their emotions and keeping themselves safe. So in terms of trauma informed cognitive behavioral therapy, it's important, it's vital to not invalidate a person's experience. What they perceived six days ago, six years ago, when the trauma was going on, was how they perceived it in that context at that point in time. Now, in this context, at this point in time, maybe they can look back and get a different perspective, but at that point, in that context, at that point in time, they were terrified. And it's important that we don't take that away from Them, it's important that we help them recognize the function of those feelings and those perceptions at that point in time. But I encourage you from a cognitive behavioral standpoint, and a lot of times when we say cognitive behavioral, people think cognitive, irrational thoughts, cognitive distortions, cognitive restructuring. Well, that's all wonderful because cognitions, behaviors, perceptions and feelings all interact. But it's important to remember that there's the behavioral components. So. So from a cognitive behavioral standpoint, in what ways do thoughts, perceptions and feelings impact agitation, irritability and hostile behavior? In what ways does anxiety impact people's behaviors, functional or dysfunctional, their other emotions, their health, their relationship, persistent and exaggerated negative beliefs or expectations about oneself, others or the world? You know, that's one of those characteristics of ptsd. But it makes sense from a cognitive standpoint when the person experienced that all of a sudden their expectations about themselves, others of the world may have been turned on, turned on their head. And if they have not reestablished equilibrium, if they have not re established a sense of safety and empowerment, then yeah, they're continuing to feel unsafe. They're going to continue to have these negative beliefs about what's going on. So it's really important that we look at the beliefs and help them identify how. Okay, maybe in that situation those negative beliefs and expectations were spot on. However, in the present, are those beliefs true about everybody or are those beliefs being over generalized? So we might look at how those beliefs and expectations and sensations were spot on, accurate, appropriate, maybe even helpful in the moment during the trauma and whether that continues to be helpful in the present. However, it's not up to us as clinicians to tell them what's right, what's wrong, what's appropriate, what's helpful. The person needs to evaluate it, look at the facts for and against their beliefs and decide is this still helpful, is this still accurate or not? And then we can help them proceed and process from there and figure out. All right, based on your conclusions, how can you become more empowered and feel safer? Hyper vigilance totally makes sense when people don't feel safe. You know, again, what we're talking about is trauma that has not fully been processed or integrated into the person's experience. And so there's a part of them that continues to feel unsafe. And when you feel unsafe, you're more hypervigilant. When you're walking to your car at 2 o' clock in the morning by yourself, I don't care who you are, you're probably going to be more alert, more vigilant about what's going on, you're going to be more hyper aware of the sounds, the sights, the smells around you, because that is a situation in which you don't feel completely safe. And again, a person who's experienced trauma and and hasn't fully integrated it is still often experiencing a lack of a sense of safety. Hyperarousal is different than hypervigilance. Hyper vigilance is noticing being hyper aware of everything. Hyperarousal is being easily startled. And when you're hypervigilant, you're likely noticing more things. You're likely feeling a little bit anxious, a little bit unsafe, which means it's easier. That HPA axis, that stress response system is already primed so it's easier to startle somebody, it's easier to prompt a stronger reaction in them. Totally makes sense. Once they feel safe and empowered and their stress response can actually check out, they can trigger the relaxation response more effectively. Then the hyperarousal will start to decrease. But it's a process. Self destructive behavior from a cognitive behavioral standpoint, why might that develop in response to trauma and to trauma related symptoms? Sometimes self destructive behavior develops because it helps the person not think about the trauma. Sometimes self destructive behavior develops because it gives the person a sense of control over their life, over their destiny when they didn't have control during the trauma. Sometimes self destructive behavior may develop in order to help a person feel something. As opposed to numbing feelings or numbing thoughts or memories, it's to help them feel something. When people are persistently stressed, when the HPA axis is on for too long, then the body naturally turns down the sensitivity of the stress response system. So people, not only are they not as startled as easily, they feel flat most of the time, but they also have difficulty with motivation and and positive versions of excitement. So sometimes self destructive behavior or adrenaline oriented behavior may be designed to help them feel something. Social isolation again makes sense because after a trauma, a lot of times other people are involved in a trauma, whether they were involved in perpetrating the trauma or whether they were involved in failing to help the person feel safe and empowered after the trauma, people can develop negative feelings about others which may lead to social isolation. Likewise, people may become socially isolated after trauma because they're so overwhelmed with their own feelings, feelings and emotions and fears and thoughts related to the trauma, they're so exhausted they can't sleep that they don't have the energy for any more input. They don't have the energy for anybody else's stuff. So they as a protective mechanism they socially isolate and feelings of detachment or estrangement from others are common after a trauma. Because when somebody experiences trauma, they're trying to get themselves safe and secure and sometimes it feels like nobody understands and or sometimes they just don't have the ability to or energy to connect with others at this point in time because they're so disconnected from themselves or so overwhelmed with themselves. So all of these things as clinicians we need to get curious and say, all right, if this developed as the result of a trauma, what function is it serving? Why did this develop in response to this trauma? How is this functioning in some way for the person? Order to help us figure out what issues we still need to address like hypervigilance and hyper arousal tell us that the person doesn't feel safe. So how can we help them feel safe? And other behaviors may be designed to help them feel something or to numb feelings of depression, anxiety, guilt, flashbacks, etc so those are. That's also something else. But we need to help them address in a way that is more meaningful and helpful to encourage them to move toward what they define as a rich and meaningful life. More trauma related symptoms Avoiding reminders of the of the event do you really want to remember the worst day in your life or the worst months or weeks for people who are enduring something like bullying or domestic violence or even the death of a loved one by cancer? Remember I said trauma is not necessarily just big T trauma. Flashbacks are often your brain's way of saying, hey, I remember being in this situation or I still have this memory, I still have this memo from this situation that nobody's filed yet and you need to figure out where to put it so we can stay safe. And flashbacks do serve a purpose. So we need to help people figure out the most helpful way to deal with those flashbacks and integrate them. Fear, anxiety and mistrust. We already talked about depression. Loss of interest or pleasure in activities and or a feeling of guilt are often common. There can be guilt because they feel like they brought it on themselves. There can be guilt for surviving. There can be guilt for not being able to be as emotionally available to the people in their lives now because of the trauma. There's a lot of reasons guilt can happen. HPA axis dysfunction is one of the main reasons for depression because it causes changes in neurochemicals. But if a person experienced trauma or traumas and they haven't made the connection between those experiences and their current state or their current behaviors, they may feel very hopeless and helpless because they they don't understand where it's coming from. They don't understand why they can't feel happy. And that contributes to hopelessness and helplessness and depression. Emotional numbness is also a common symptom of after trauma because the emotions that they felt were so overwhelming that they just put a barrier between themselves and those feelings. So it's. They feel anhedonic. Now, some of that can be cognitive, some of it can be neurochemical. It's important to remember that during stress, when that HPA axis is active, it alters the proportion of the different neurochemicals. And it's possible that after an extended period of time, the person may not have the right balance of neurochemicals to feel particular emotions. They may be in this flat state that I mentioned earlier. Sleep problems, including insomnia or nightmares, are also really common in trauma. Now, not everybody remembers the content of their nightmares. Insomnia and sleep problems is a common symptom of depression, but it's also a common symptom of trauma. So we need to look and say, okay, well, maybe this person is presenting with depression and sleep problems. Is there also underlying trauma that is promoting that feeling of helplessness and hopelessness and keeping them from feeling safe enough to actually get good quality sleep? Difficulty concentrating, we need dopamine, we need norepinephrine in order to concentrate. When that HPA axis is overactive for too long, our levels of dopamine and norepinephrine decrease. Additionally, if people aren't sleeping well, it's going to impair their concentration. If people are hypervigilant, it's going to impair their concentration. It's hard to focus on a spreadsheet when you don't feel safe and you're hyper vigilant to every flicker, every move, every sound that goes by. So we need to get. I know I've said this 16 times already, but we need to get curious. And that is probably my battle cry for this entire presentation, is instead of assuming that, okay, difficulty concentrating is a symptom of depression, blah, blah, we need to say, why is the person having difficulty concentrating? What is causing that? What is preventing them from being able to cognitively focus? Is it a lack of a sense of safety? Is it low dopamine, low norepinephrine? Is it depression, or is it something else? Chronic pain is also common in 15 to 35% of people with PTSD. So let's talk about a case example just to kind of put this into perspective. Sally is nine years old, in third grade. Her dad was never in the picture and her mom is addicted to painkillers and clinically depressed. Sally's mom will often disappear for days. But even when she is physically present, she's either out of it, crying or angry. So think about how does this represent a trauma? Is there a particular major trauma? No, but what we're seeing is adverse childhood experiences where seeing a caregiver who is emotionally unavailable, a caregiver with an addiction or a mental health issue, we're seeing abandonment. Dad completely abandoned. Mom will disappear for days on end. So yeah, Sally, a nine year old obviously is likely going to have a lack of a sense of safety. She's kind of out there on her own. And then when mom is present physically, she's either stoned out of her mind or detoxing or experiencing cravings and she's crying or angry and irritable. So from a nine year old's perspective, it's really hard to predict what's going on. There's a lot of chaos in the environment. Now, initial relationships, our initial secure attachments are supposed to help us develop emotional intelligence so we can label our emotions and learn how to effectively modulate our emotions through the help of somebody who already knows how to label and modulate their emotions. Well, Sally ain't got this. So now Sally's all grown up. She is presenting with generalized anxiety disorder, borderline personality, persistent depressive disorder, with intermittent major depressive episodes and dissociative disorder. I figured I would just put as many diagnoses as possible in here. So why generalized anxiety? Well, think about it. When Sally was growing up, she didn't have people providing nutrition for her. She didn't even know if somebody was going to go to the grocery store for her. She wasn't sure when or if mom was coming back. Every time mom would leave, she wasn't sure when or if mom would wake up. When mom was asleep, she wasn't sure about how to get to school. She wasn't sure if she was loved. She wasn't sure about anything. So as an adult, she never learned how to cope with events that happen in life. She didn't develop emotional intelligence. And because her childhood was so chaotic, all of those behaviors often and experiences often continue into adulthood. If she is, if she doesn't have somebody that's helping her with that, which she doesn't. Right now, Borderline personality disorder is very common in people who experience adverse childhood experiences and childhood trauma. Now, you could argue that it's CPTSD, but CPTSD is not an actual diagnosis in the DSM5TR. So we going with what we have borderline personality. She vacillates between devaluation and idealization of people. Well that makes sense. A nine year old thinks in dichotomous terms. They love me, they hate me. Sally personalizes everything. A nine year old is very egocentric. They have difficulty things thinking abstractly about, well, maybe mom's acting this way because of the drugs or because of detox or because of something else. It's about me as a nine year old it must, it's directed towards me, so it must be about me. So we have dichotomous thinking, we have personalization, we don't have anybody contradicting that for that nine year old. And a lot of us don't aren't taught to go back and evaluate the ongoing effectiveness of our schema of our expectations. So as Sally grew up, she maintained that dichotomous thinking. She maintained that especially in terms of people. And mom seemed to be pretty dichotomous herself and the personalization. She internalized a lot of things and that's how she learned to understand the world. It's all my fault. The persistent depressive disorder. So there for more than two years she's experienced symptoms of depression which occasionally rise to the level of meeting the criteria for major depressive episodes. Long term HPA axis dysregulation as a result of trauma can lead to persistent depressive disorder or major depressive disorder. So that makes sense. In Sally's environment that she grew up in, she probably had a sense of helplessness and hopelessness. Her HPA axis was probably on all the time because she didn't feel safe. So it would make sense that her neurotransmitters are out of whack right now as well as her perceptions may be out of date. Remember back then she was thinking in ways that are appropriate and developmentally accurate for a nine year old. Now that she's an adult, she has the ability to think more abstractly. But she may not have considered those options. And dissociative disorder, Sally, when she gets stressed, sometimes checks out. And that was a behavior that she developed when mom would go on her rages or when her anxiety would get too high. When she was home alone, she would just completely check out and quit feeling anything. She would dissociate and she would have these periods of, and still has these periods of time loss. So it's important to really look at these symptoms, not look at the behavioral label, but look at the symptoms for each disorder or condition and ask yourself. How might each of these symptoms have developed as a result of the trauma or as a way to help Sally survive when she was a child? How do they make sense. Physically? Sally, as I mentioned, likely has significant stress response. HPA axis dysregulation. When people experience trauma, the schema become encoded and the connection between their amygdala, which is where fear processing is, and their default mode network or their autopilot becomes much, much stronger. So basically their fear network is constantly tapping on that autopilot going is there a problem? Look for threats. Is there a problem? Look for threats. And that connection becomes so strong that sometimes the executive control network or the wise mind as Linahan calls it, has a hard time taking over, has a hard time turning off autopilot. The HPA axis dysregulation leads to a whole host of physical problems, as I mentioned earlier, and I do have another video on the YouTube channel about the neurobiological impact of trauma. If you want to get into all the nitty gritty. But it's important to recognize that the structure of the brain actually changes. It's not just people's thoughts, but it's the structure of the brain and the balance of the neurochemicals actually change after extended exposure to stress and or trauma, which contribute to sleep disruption and exhaustion. And sleep disruption and exhaustion cause that HPA axis to ramp up even more and try to dump excitatory chemicals to help the person stay awake. Nutritionally, people who've experienced trauma may self soothe with food. You know, Sally never learned healthy eating. Mom wasn't making breakfast or lunch. So we're going to hypothesize that she grew up on a solid diet of fruity pebbles and peanut butter and jelly sandwiches. Pain and or muscle tension is common in people with anxiety. When we are stressed, our body says hey, you need to stay primed, you need to stay alert so you can respond in the event of a threat when which is why people's muscles stay sort of tensed so they're already coiled and ready to spring. Alcohol abuse. Sally didn't turn to painkillers because she saw what it did to her mom. But alcohol was also very available in her household. And Even as a 9 and 10 year old, she would turn to alcohol use in order to quell her anxiety when mom was physically or emotionally absent. And non suicidal self injury is another physical symptom that she's displaying. And Sally engaged in non suicidal self injury in order to help stop the anxious thoughts, in order to help stop the ruminations. When mom would disappear for days at a time, sometimes she would engage in that. So that took her entire focus. When she was engaging in that behavior, she wasn't thinking about other things. When she was engaging in that behavior, she had control. Affectively. Sally experiences a lot of emotional dysregulation or emotional lability. Well, she never developed emotional intelligence. She didn't have a secure attachment. She didn't have anybody in her life that taught her how to identify emotions and how to cope with them. So it makes sense that she's lacking the tools to regulate her emotions anyway. But couple that with an HPA axis that's dysregulated. So she goes from feeling flat to furious. She goes from not feeling much to a tsunami of stress chemicals. And it makes sense from a neurological, biological standpoint how she may emotionally dysregulate. Now, cognitive behavioral interventions. Cognitively, we can help her explore strategies for identifying and coping with emotions and coping with distress. But behaviorally, we also need to help her develop skills and tools in order to help her brain and body recover, help her brain and body not constantly be in a stressed state. State which includes good nutrition and sleep and relaxation exercises and vagus nerve stimulation. Depression and generalized anxiety especially, and anxiety about abandonment are also very prevalent for her. And exploring again the cognitions that are contributing to her feeling hopeless, helpless, or unsafe, that's important. And helping her identify cognitive ways and environmental ways to deal with those, but also helping her understand the importance of behavioral interventions, what physical things and what behaviors make her more vulnerable to depression and anxiety, such as not getting enough sleep or over caffeinating or drinking alcohol. So we need to help her explore how some of her behaviors may be contributing to or maintaining her unpleasant feelings, as well as the cognitions. Anger management difficulties goes along with that emotional dysregulation. If you don't feel safe, then you are already. That HPA axis is already on and primed. And when something intensifies that feeling of threat, then you're going to respond either with anger or anxiety, with fight or flee. So her response being already, already feeling unsafe, already being primed. When she feels unsafe, she lashes out. You know, flat to furious. She lashes out because there's a tsunami of stress chemicals. And it's important to help her understand that, that some of what's going on is a physiological response that can be corrected, but not to assume that it's quote, all in her head to help her recognize that when she has that tsunami of, of cortisol and glutamate and Fight or flight chemicals that it's important to use distress tolerance skills in order to ride the wave until she can get into her wise mind and make more accurate judgments. Sally also carries with her a lot of guilt because she still feels like it was her fault or some things were her fault in her childhood. But she also recognizes that because of her depression, her anxiety, her trauma, her everything that she's presenting with, she has harmed some of her relationships. She has damaged some of her relationships, and she holds guilt for that. So we need to explore, what do you feel guilty about? Remember, guilt is anger itself for mistakes that you made and how can you cope with that? What cognitive strategies can you use and what do you need to do? Maybe the need to make amends, maybe you need to set better boundaries. What is it that you need to do in order to behaviorally and cognitively in order to address that guilt and grief, not uncommon in people who have adverse childhood experiences. She grieves the lack of that. Warden June Cleaver Leave it to Beaver family. She grieves not being able to have the childhood that she deserved. Helping her process her grief is going to be important. Helping her make a list and identify her losses and work through those is going to be important. Cognitively, Sally feels hopeless and pessimistic. A lot of her cognitions remember we're all or none thinking and personalized, and they've kind of gone unchecked over the years. And so it will be important to use cognitive behavioral tools like we'll talk about in the next video, like hardiness and creating a rich and meaningful life vision board to help her identify what she might want to work towards. Inflexible thinking is very common in people with who've experienced trauma, all or nothing thinking, personalization and mind reading. You know, again, as, as a child, she thought in all or none terms. Go back to Piaget. You'll find that that's pretty common in children. Personalization, egocentrism education is very common in children. So she still holds some of those inflexible thinking patterns. And then she developed this cognitive distortion of mind reading in order to stay safe. It was important in her experience to anticipate, to the best of her ability, her mother's every need in order to prevent the rages. So, so she learned the only way to stay safe is to try to preemptively anticipate what people need without asking, just you need to know. And that creates a lot of stress because it is not possible to read people's minds. She has difficulty with problem solving, concentration and decision making, largely due to her HPA axis dysregulation that's caused disruption in her dopamine and norepinephrine levels, but also her hypervigilance. You know, she still doesn't feel safe in relationships, even in environments where she doesn't feel like she's going to be physically harmed. She is scanning for people who might get angry with her for some reason and, or, and she's constantly hyper vigilant to possibly making mistakes, which may mean that she's not worthy or not lovable, and then dissociation. So we need to help Sally figure out understand how dissociation function for her, but also help her figure out tools like narration and grounding strategies to help her manage her dissociation interpersonally. Sally has low self esteem and an unstable sense of self. Well, she was constantly getting raged on by her mother. She grew up in a very unstable environment. She didn't have anybody that we know of cheering her on and saying, you're awesome, you're lovable. So she grew up trying to get reinforcement, trying to get approval from people by being whatever she thought they wanted her to be. So she had this chameleon esque ability which helped her survive. But now she doesn't know who she is or what she likes because she was always trying to be what everybody else wanted her to be. She engages in frantic efforts to avoid real or imagined abandonment. When she gets into relationships, she's still craving security like all of us do, but she can't seem to create secure attachments. And she's hyper vigilant to those cues in the environment or in the person that may have been put off by her mother or other people in past relationships that were preludes to abandonment. We need to help her identify those triggers and process those, learn from them, learn how to develop secure attachments, unhealthy boundaries. You know, when you're trying to get approval and trying to get somebody to tell you that you're worthy of breathing the air and trying to be whatever you think they want you to be. A lot of times that also means having unhealthy boundaries. And that can mean having really weak boundaries and letting them, you know, tell you what to think, what to feel, how to behave, or very, very rigid boundaries where you push people away and you can't understand their perspective. In Sally's case, her boundaries were very weak, defensive or passive communication. She never learned how to assertively state her wants, feelings and needs, partly because she didn't know what they were, but also partly because if she tried to, it was met with a lot of anger and invalidation. So instead of stating her needs, she just, you know, let it go. She let it be quiet. She was very passive in her communication. Other people may develop a defensive strategy where they have to be right, they have to be in control, and they can't hear other people's perspectives because that's how they developed their strategy to stay safe. And projection. Sally regularly projects onto other people what she expects based on past experiences. And it's important to help Sally start practicing tools like fact based reasoning so she can look and say, all right, this is what I'm seeing, but is this what's actually happening? This is what I am perceiving, but is this the whole picture? What are the facts? For and against my belief, for and against my perception, this context with this person at this time, you know, if my mom would have done that or if Jim Bob would have done that, it may have meant something completely different. But in this context with this person at this time, what does this behavior mean? So there's a lot of helping Sally understand the importance of healing both her mind and her body. And in order to feel safe and empowered, it's important to help Sally understand that her behaviors, it's not just changing the way she thinks, but her behaviors that will nurture her physical health and help her create safer environments are also going to contribute to her recovery process. We need to help Sally look at triggers and, and just kind of as a side note, you know, the smell of people in the past that traumatized her like cigarettes, cologne, or shampoo. Seeing somebody that looks like that person, seeing happy families or likewise, seeing families that look like hers. Feeling loved can trigger extreme fear. Hearing happy children playing or parents being neglectful in real life or even in the media, like on TV or people using painkillers. Those are just some examples of triggers that we might want to help Sally identify. You know, help her identify what triggers your anxiety, what triggers your stress, what triggers your sense of hopelessness and helplessness, and just I give up. And help her connect those triggers and understand why they trigger that feeling and then figure out how she's going to cope with those trauma informed. Cognitive behavioral therapy recognizes symptoms as a reaction to trauma. It seeks to help people develop cognitive and behavioral strategies to feel safer and. And more empowered to address their symptoms. It avoids invalidating people's experiences by trying to change their perception or memory of the event. It helps them embrace the and when you were six or nine or whatever, you experienced this and this is how you perceived it. All right? That six year old you has that perception. Now the 26 year old you, Is there anything else you would add to that, or are there alternate things to add to that picture? We're not saying that the child's perception was wrong. That was the child's perception and we need to process it and process how the child felt. And we need to also look at it with fresh eyes to see if holding on to that same belief system and those same schema in the present is going to continue to be effective. In the next video on trauma informed cognitive behavioral therapy techniques, I will explore specific techniques and tools and how to use them in a way that resists retraumatizing the individual.