PTSD Exploring the Function of Symptoms | CBT Counselor CE

Hi. I'd like to welcome everybody to Today's presentation on PTSD, exploring the functional nature of systems. I am Dr. Donnellice Snipes. In this presentation, we're going to review PTSD symptoms, which most of you are probably really familiar with. So it's not going to be anything new, but we're really going to look at it from a functional perspective. How, how do these symptoms make sense in terms of helping a person survive? And then we're going to talk about alternate interventions to meet the same needs. By understanding the function of symptoms, we can normalize behavior for clients if we present it to them and say, okay, I realize that hyper vigilance is really freaking annoying, but let's talk about how that might make sense, how your body is actually trying to help protect you because. Because it doesn't want you to experience trauma again. We're also going to identify alternate ways to meet the same need or address the same issue. So you're going to talk to clients and go, okay, hyper vigilance is trying to keep you from being surprised again. So what can you do? So when you're sitting at home or you're sitting in a restaurant or wherever it is, you can feel calmer, like, you don't have to be on guard all the time. So you can feel. Feel like you're safe and not going to be caught by surprise. And feng shui, if you are into that, and actually, I think it's Feng shui for dummies is a really good primer on feng shui techniques. But one of the principles of feng shui is you always want to be able to see what's going on behind you. Therefore, you don't want to have your back to a window or to a doorway, because then people could theoretically sneak up on you. So, same thing. When you're sleeping, you'd want to be able to see all the entrances and exits. And if you can't, put up little mirrors so you can see, put up a mirror on your monitor. Put up a mirror, they suggest, on the kitchen stove. Because when you're at the kitchen stove, people can walk behind you, set yourself up so people can't startle you. Which is also really good if you have teenagers in the house because they like to sneak up on you. But I digress. So feng shui can be something that you can look at to help people arrange their environment to reduce their internal stress some, and we're going to talk a lot more about that. But that's one of the things that you want to talk about with clients and say, okay, it makes sense. Now, how can we help you feel more comfortable? How can we help you integrate this experience and create an environment that is your new normal, that is your new comfortable? So PTSD is caused by exposure to death, threatened death, actual or threatened, serious injury, or actual or threatened sexual violence through direct exposure, witnessing, learning that a relative or close friend was exposed to the trauma, or indirect exposure to aversive details of trauma, usually in the course of professional duties such as first responders and medics and soldiers. This does not apply to media exposure unless work related, according to the dsm. Now, I'm going to go off on a little soapbox here. So this is my personal opinion, not DSM's. When we're talking about children, children have difficulty separating what's on TV from what's going on right outside their front door because it feels like it's in their living room. And that is really important to recognize. For example, you know, way back when on 9, 11, they kept playing that twin tower thing over and over and over again. And my child at that point was two years old, something like that. But to him, that was going on right now and right outside because he didn't have a concept of, you know, where the Twin Towers were. He also understood that mommy and daddy were getting really stressed out about it. And so he was trying to put it together and figure out if he was safe. And children will do this. Children are very sensitive to how their parents react. They also, again, have difficulty differentiating what's on TV from what might be right outside their front door. So I would argue that with children, not with adults, but with children, media exposure, especially continued media exposure, can be a source of trauma for some children. If not all trauma causes long term dysregulation of norepinephrine and cortisol systems. Now, norepinephrine is your get up and go chemical. It's also one of your focus chemicals and your cortisol system, that is your fight or flight system and vulnerable areas of the hippocampus, amygdala and prefrontal cortex. Now you remember the hippocampus involved in that cortisol system with the HPA axis, your stress response system that I call it. And your amygdala is that primitive area of the brain that's involved in fear processing. And a lot of times traumatic memories may get stuck in the amygdala because your brain doesn't know how to assimilate them, which leads to problems like PTSD and The medial prefrontal cortex is where a lot of our impulse control happens. So when these things, when these areas get dysregulated, we get basically turned on high, if you want to think about it that way in all of these stress response system because the body doesn't want to be surprised and it wants to be on guard, it wants to be aware. I played tennis in high school and one of the things that you never wanted to stand flat footed because you didn't know when the person, where the person was going to hit the ball or where it was going to become coming. So you always wanted to be bouncing on your tiptoes ready to move to meet the ball. Same sort of thing with hyper vigilance and hyperactivation and ptsd. Your brain is going, okay, we need to be ready, we need to be ready, we need to be ready. It makes sense. Your brain doesn't want to die and it experienced whatever that threat was as threatening to its system. Now, before we leave this slide, let's just take a little journey over to adverse childhood experiences. Again, doesn't necessarily exactly meet the PTSD criteria, but given all the research, I think we've realized that they're still important to consider because they do represent potential trauma. Children who grow up in an environment where there's uncontrolled mental illness or addiction. And I say uncontrolled because there's a lot of us out there who have mental health diagnoses, clinical depression or whatever, or even people who are in recovery from an addiction and they are wonderful parents and they are wonderful spouses and great employees and all that kind of stuff. So I don't want to say just because a person in a household has a mental illness or an addiction means the children are going to be traumatized. No, if it's uncontrolled and it is causing problems in that caregiver's ability to respond to the needs of the child, then it can become traumatic. Children are thinking very primitively. Children somewhere deep down in their brain they know they can't survive without their caregivers. So if their caregiver is non responsive, if they walk in on a caregiver who was passed out in the bathroom after shooting up from heroin and they can't wake him up, that's going to be pretty dagum traumatic. If they walk in on a caregiver who's passed out drunk and again can't wake them up, or, you know, you can see the scenarios, or if you have a caregiver who is struggling with clinical Depression and just can't even get out of bed and may exhibit some suicidal tendencies that can be really traumatic to the child for a lot of reasons. But this is what I'm talking about in terms of trauma. Parental abandonment, whether it's the parent leaving the household forever, not just to go to work, whether it's the parent disappearing or going to jail, or even in some cases getting deployed and going overseas. Most of the time that's not as big of an issue because the caregiver, even when they're deployed, is able to communicate with the child. But if there is a significant period based on the child's age, a significant period of abandonment by the parent, or missing, the child can experience some trauma related issues based on how they process, you know, what happened to my caregiver. If parents die, you know, that's definitely going to be a traumatic incident for a child. And obviously abuse. Whether it's direct, you know, the child is experiencing the abuse, or, or indirect, they're watching, they're seeing domestic violence or they're seeing child abuse to a different sibling. Those things can also be traumatic to a child. We want to consider, when we're thinking about PTSD symptoms, we want to consider that. And that's exactly where I was going with this, Lisa. Not every trauma is, or not every situation is traumatic for every person. For example, if a person, let's say a young child, just to highlight it, sees a dead body, you know, that could be very traumatic to them, probably will be. A coroner is going to see a dead body on the hour and that's not going to be traumatic to them. Even if it's, you know, there are some pretty gruesome ways people die. Part of it is being able to control the situation and feel empowered in the situation and feel safe, if you will. The coroner feels very safe in his or her lab. The child who walks up upon a dead body is not going to feel so safe. So that could be traumatic. You also might have children, you know, let's stick with the same scenario, who walk up on a dead body, who aren't traumatized. They're like, oh, that's bad, but kind of cool, you know, some children are fascinated, not in a serial killer kind of way, but in a scientific sort of way about what happened. So we don't want to assume any particular incident was traumatic to any particular person. We also want to make sure that we're considering the age of the person who experienced the trauma in terms of understanding the impact of the trauma. So for example, a six year old who's one of his caregivers just up and disappears one day, goes out for milk and never comes back. That's going to be devastating and could be extraordinarily traumatic to that child. If a 26 year old caregiver, you know, up and disappears one day, decides they're going to move to, you know, across, across the world and doesn't tell anybody, it's going to be devastating, but it's not likely going to be nearly as traumatic because a 26 year old can take care of themselves. They've got their own lives now and they're not completely dependent on that caregiver. Think about it after a trauma, and I'm not saying one that necessarily even caused ptsd, I'm just calling talking about after a trauma. How does it impact your sleep? Most of us have sleep disturbances after a trauma. Think about if somebody in your family was diagnosed with a terminal illness and died unexpectedly or really rapidly after that. That could impair your sleep for a while. Now. Some people want to sleep all the time because they just can't deal with the world and they don't want to face what happened. Some people can't sleep, sleep at all because they're anxious. They don't want to go to sleep because they're afraid if they do, they may not wake up. It affects people's mood. Some people feel depressed, hopeless, helpless. Sometimes people feel anxious because they don't want to experience that trauma themselves or again, they don't want to die. They may feel angry at a variety of, you know, their higher power, the person themselves, for a variety of reasons. And that's a whole different presentation. They may feel guilt over things that they didn't do or things that they wish they would have done and grief. You know, after a trauma, we grieve things, we grieve the loss of the life that we knew before that trauma. No matter what that trauma is, our life has changed a little bit. That chapter of our life, if you want to think of it as a book or that season, if you want to think of it as a TV series, is over. You know, the seasons come to an end and we've got to move on. So there's a certain amount of grieving that has to be done. Our perception of people in the world may change and especially if the trauma involves some sort of victimization or crime. But even if not, even after Hurricane Andrew and Hurricane Katrina, people's perception of the safety of the world and one another changed a lot because, you know, there was Looting. And there was, you know, there were some people that were super helpful and then there were some people that just kind of went with their ID impulses and there was a lot of disparity. So people's perception of one another changed greatly. And we'll talk about this more later. Your sense of safety can be impacted, whether it was a hurricane. You know, every time a hurricane comes in Florida, we know every year there's going to be hurricanes. And when you see a hurricane coming your way, it can trigger trauma symptoms. For people who've been through really bad hurricanes before, they may not feel safe. For people who have been victims of crime, you know, how does that impact their feeling of safety when they're walking to their car, when they're home alone at night, when they are at work, you know, whatever. And your perception of efficacy after a trauma, a lot of people feel helpless during the trauma. And their sense of efficacy, their sense of their ability to protect themselves and to prevent that problem from happening again, may feel a little bit impaired on the other side. Some people go to the other extreme and try to take extreme control of everything. So they want to. If they were victim of crime, they may start putting up, you know, 15 locks on their doors and getting two Rottweilers and putting in an alarm system and floodlights and, you know, just trying whatever they can do to make themselves feel comfortable again. From a survival point of view, these things make sense. You know, when we think about what happened and the way our brain is tending to it, our symptoms make sense. Even if, you know, our sense of safety is probably changed, at least initially, in an over generalized sort of way, you may think you'll never feel safe again. Well, that's a pretty over generalized statement, but I can see where it comes from, your perception of your ability to keep yourself safe. Well, if you didn't expect it, had no way of anticipating it, and it seemed to come from out of the blue, I can see where it would make sense that you might feel like, can I even protect myself in this world? Totally makes sense now. It's what we do with those thoughts that is important. I don't want to tell people that that's not an okay thought to have because it makes sense. It totally makes sense now. What are we going to do about it? Remember, with ptsd, symptoms have to have lasted for more than a month. Prior to that, we're dealing with acute stress disorder. If symptoms are going on for more than a month, that means something is not integrating well. When we do experience things and this goes back to, I believe Piaget. We form schema and these schema we call on to help guide our lives. When you go to work, you know, every time you start a new job, you're going to form schema about how you're supposed to dress, what you're supposed to do as soon as you get in, how you interact with certain people. Whenever a new employee is hired, you're going to interact with that person and you're going to develop a schema of who that person is and how to interact with them and you're going to add that and it just assimilates and it builds and it's basically like building a little library in your head. With ptsd, this traumatic event happened and you're sitting there going, I don't know how that happened. I don't know how to protect myself. I don't know how to keep it from happening again. I'm kind of at a loss. And in those circumstances, a lot of times that memory just kind of sits in the amygdala. And the amygdala says, okay, I'm going to just keep this on the back burner for right now because I don't know how to make sense of this situation to based on the world that I thought I lived in. And it's just kind of stuck here. When I was little, we used to do a fair amount of boating and if you've ever been on a boat, you know that the boat goes up and down, especially out on the Atlantic. And when you would get back onto shore and even if you've been on a cruise, you're going to feel this way a little bit. When you get back onto shore, your legs would feel kind of wobbly getting on shore because you were used to the undulation of the waters and you had to get regrounded once you got back onto onto land. And that's kind of what we're doing in helping people resolve trauma. When they've got ptsd, they're never getting their land legs back. They're always waiting for that next big wave. We want to help them feel like they're flat footed. Re experiencing is one of those categories of symptoms that they talk about. With ptsd, we re experience things every day. We access things schema that guide our actions when we go to work. Like I just said, when we encounter a particularly volatile client, we have schema for how to handle that. I know I've had a few in my day and they have changed my perception and made me more alert to certain Characteristics to watch out for, etc. That lets me know that, okay, this person may be getting ready to become volatile in some sort of way. But I add all that to my schema, I integrate it. I feel confident that that information now can help me. And bada bing, when you approach a stoplight, that's another schema. That's one of those early on schema, you know. And depending on who you are, when the light turns yellow, your schema may say gun it because you're going to get through the light. But. Or you may have the schema like mine that says stop. And that schema affects how you behave. In ptsd, people re experience this trauma. A lot of times when they experience triggers, things that remind them of the trauma, that schema is called up and they're put on high alert. Again, the context is often over generalized. So for example, a child may be afraid of all strangers if there was an abduction in their family or something. Or after a plane crash, a person may be afraid of all airplanes. All airplanes are scary things. They're gonna crash, yada yada. Or if somebody is a survivor of a home invasion, for example, then being alone may be the trigger that causes them to re experience. I had a friend, and I've told this story before, a client who was a first responder to a really bad car crash on the interstate. And triggers for his PTSD included just the smell of car exhaust. Now, when you're driving home tonight, notice how often you smell car exhaust. So he was re experiencing this thing, you know, on the daily. Another thing that makes re experiencing problematic or troublesome in PTSD is the precipitating factors for the trauma are often unknown. You know, it came from out of the blue. You weren't expecting to be robbed. You weren't, you know, you had walked home or walked to your car in the parking garage 363 times before and not had a problem. But on the 364th time you get robbed, you know, and they're just like, okay, so the parking garage is not safe anymore. And then they start looking at, okay, what else is not safe? Well, it was at night when this happened, so maybe it's not safe to be out at night. And things start getting over generalized. So the person can try to figure out, okay, where can I be safe? And in many cases in trauma, the resolution is not one of empowerment. So the person is continually trying to figure out how not not to be disempowered. If a child experiences the sudden death of a parent, you know, the child may blame themselves for what happened to the parent or blame themselves for not being able to save the parent. Or likewise with a child, when you have Sudden Infant death Syndrome. We see this a lot in grieving parents who go through the shoulda, coulda, woulda's and, and try to figure out, you know, how can I prevent this again? And, you know, how was this completely out of my control? People tend to have intrusive, distressing memories of the traumatic event. And in children, repetitive play may occur in which themes or aspects of the traumatic event are expressed. Well, they're trying to figure out how to make this turn out right. It's kind of like rewriting a script over and over and over again. And these intrusive, distressing memories may also come out in order to help protect the person. The brain's going, yeah, this reminds me of a time that you don't want to go back to, so, you know, let's fight or flee. Recurrent distressing memories in which the content or feeling of the dream is related to the event. In children, there may be frightening dreams without recognizable content. So for a lot of us parents, when our kids wake up with a nightmare, we want to tell me what happened, tell me what was going on in your dream, because we want to demystify it and help the child realize logically what's going on. But with ptsd, there may not be any recognizable content. And we don't want to say, well, I can't help you. We want to understand that that's sort of the artifacts, or the shadows, if you will, of the trauma from the amygdala coming out, and the amygdala is going, I'm still not sure we're safe, so I don't want you to sleep too soundly. Flashbacks or other dissociative reactions in which the individual feels or acts, if the traumatic events are recurring, and again, you may see trauma specific reenactment in children's play. When these flashbacks occur, you actually feel like you're in that situation again. You feel like you're being watched, or you feel like somebody's walking up behind you or whatever it was that happened. You may feel like that's getting ready to happen again. So you become on high alert. And this can happen as a result of smelling a smell, a certain light level of a certain sound, or certain people, places, or things. You know, there are a lot of things that can trigger the brain to go, oh, boy, I remember something like this happened before. An intense, prolonged psychological or physiological distress at Exposure to the internal or external cues that symbolize or resemble an aspect of the traumatic event. When the person recognizes when the brain is cued in and it goes, oh, that reminds me of a time. Then the stress response system, the HPA axis is going to kick off and it's going to go fight or flee. Danger, Will Robinson, danger. And that makes sense. That makes sense that the body doesn't want to be there again or doesn't want to be there ever if it was something that the person didn't experience directly. Okay, you know, so help clients understand that so they can wrap their head around it and go, okay, I want to survive. And my brain is just a little overactive, over sensitive right now. It's trying to help. The brain is trying to help the client avoid future similar situations, learn how to protect during future similar situations and assimilate what happened into their schema. They're trying to figure out how to make sense of it because they had a perception of the world as, you know, at least their corner of the world as a safe place, as a place where they had no harm. During the student murders in Gainesville back in 1990, something, wow, it's been a long time. You know, we felt before that happened, we felt like being on campus was the safest place in the world. And UF is a pretty big campus. And you know, and I'll tell you, I was out at 10 o' clock at night with headphones on running and couldn't hear padiddly squat going on around me because I felt safe. And after those started to happen, you know, I was like, okay, well this place that used to be, you know, we thought this safe utopia ain't that way no more. So we need to adjust our schema to fit this situation in it so it makes sense in order. Instead of saying, okay, that campus is a dangerous place to be, we had to assimilate it. So we recognized that it's no more or less dangerous than the outside world. But there are precautions that we have to take with re experiencing therapy. Goals are to help the person differentiate the trauma from general life situations like what I was just talking about, you know, this particular situation was a particular person that, you know, decided to go on a killing spree. But that doesn't mean that all people are dangerous. That doesn't mean that the campus itself is always a dangerous place. 99.999% of the time, it is a perfectly safe place to be, at least in terms of, you know, getting killed. Recognizing that and recognizing where common Sense has to kick in that, okay, what do I need to do to be safe on campus and what do I need to do to protect myself in the world that we live in today? Just like recognizing reality, and for some of us, it is a unpleasant wake up call because we really like to believe in our utopian world. But helping people assimilate and differentiate the trauma so they don't feel like all situations or whenever you're alone, you're in danger, explore the facts of the situation. What actually happened? You know, let's talk about the facts. What happened and what did you, and what did you not actually have control over? You know, there are a lot of times when people reflect on a trauma and they think, well, I should have or I could have, and hindsight is 20, 20 or better, if you will. And yeah, there may have been some things that you could have done, but in the moment, you were trying to survive in the moment during, under those circumstances, you are not thinking clearly on all cylinders. That's just not how we're designed. We're not designed to sit there and problem solve and go, okay, you know, there are six options I have here. I've got a gun pointed at me, which one should I choose? No, your brain is designed to tell you to get the hell out of there. Helping people recognize what they had the capabilities of doing and what was out of their control. To help them assimilate and identify their feelings and then move on to helping them identify ways they can can feel safe in their current situation, given what happened. And remember, traumas are not always victimization. Traumas can be, for example, finding out that your caregiver has cancer or your significant other has cancer, or you have cancer, that can be really traumatic. So how can you feel safe? What can you do so you can feel like you can enjoy life and not have to be concerned about everything you put in your body is going to cause cancer, or every time you go outside you're going to get attacked or whatever. What do you need to do so you can feel calm and enjoy and have a rich and meaningful life. And finally, people need to learn how they can cope with these intrusions. Because just going through this cognitive stuff doesn't mean that the nightmares are going to stop right away. It doesn't mean that the flashbacks are going to stop right away or at all sometimes. Generally they will slow down significantly, but people will periodically, often still have flashbacks. The hope is with things like EMDR that that is not true. But with general cognitive behavioral interventions, a lot of times people still have occasional flashbacks or nightmares. So how do you deal with that? When you wake up in a sweat, what do you do? I worked with a unit of men who were soldiers and they would wake up with night terrors. And we had to figure out, okay, when this person wakes up with a night terror, what needs to happen. And in a lot of those situations, we had a very dim nightlight in the room, so they weren't completely in the dark. And then they had the ability to turn on a light. And we had a procedure for them to follow that helped them get to ready regrounded in the moment, in the present, because they were often flashing back to the past. Avoidance is another symptom. Avoidance of recurrence of pain or arousal of the stress response system is basically what's going on. This person has been overwhelmed. Going through a trauma is exhausting. It's overwhelming, it's terrifying. It's all of those big excitable words and you don't want to do that again. That was really horrible. So avoidance makes sense. Your brain is going, you don't really want to go there. It's like saying, do you want to put your hand on a hot stove? And of course you're going to go, no. Well, people don't want to put their brain on a proverbial hot stove. They don't want to experience that again. So they may avoid people, places, activities or anything that may trigger a sensation. Sensational sense, reminder of the trauma, like smells or sights, those are all things that make perfect sense. It's the brain's way of going, I can't, I just can't right now. People may start to experience emotional numbness and we're going to talk about this a little bit more when we get to hypocortisolism in a few minutes. But the brain is trying to protect the person from being overwhelmed, from being completely discombobulated. Another way or method of avoidance is an inability to remember important aspects of the traumatic events not due to head injury, alcohol or drugs. People go through this. And in the course that I did on the neurological aspects of trauma, we talked about how the brain secretes certain hormones when there's a trauma that actually prevent the formation of memories. Why? Because the brain doesn't want you to remember it. It was too horrible. That makes sense to me when you think about it that way. Now as cognitive beings, we want to understand and we want facts and we want details. But sometimes our brain says, you know what, you don't need those. It's better you don't remember. That's something that we want to impart to our clients. You know, some of these things you may never remember because of your brain chemistry. At that point in time, your brain is going, that's not something you need to remember. And you're going to have to figure out how to be okay with that. An exhausted system conserves energy. Case there's another threat, and this is hypocortisolism. When a person is hypervigilant and hyped up for too long, eventually the body goes, you know what? We can't fight this threat. So we need to start holding on to some energy. We can't stay revved up this long. Otherwise, when that tiger comes to eat us, we're not going to have the energy to get away. So we're going to start conserving energy. Well, the problem with that on a lot of fronts, but a problem with that is that that energy it's conserving is not only the energy to fight or flee, but it's also the energy to be excited and elated and happy. It's holding on to all of those excitatory neurohormones that it needs in case there's another threat. So the person may start feeling feelings of detachment or estrangement from others and have a persistent inability to experience positive emotions. Another thing that's going on here is hormonal changes have happened. Under chronic stress, cortisol impairs thyroid function. When thyroid function is impaired, we start to feel more depressed. When thyroid function is impaired, our serotonin levels are also impaired. So you have this cascade effect that can lead to a lot of different cognitive and emotional issues. So recap on hypocortisolism, Cortisol is the stress chemical. After extreme stress or under chronic stress, the brain may reduce the responsiveness of the stress response system or the HPA axis by reducing cortisol. This is protective. When our brain has too many excitatory neurotransmitter going through our brain, especially glutamate, but it actually becomes what they call neurotoxic. It becomes too stimulated and it starts killing off neurons. We don't want that. We see a lot of neurotoxicity in people who abuse stimulants, for example. But I digress. So the brain's going, I don't want to start losing neurons. I like all the neurons I've got. So we're going to tone it down a little bit. We're going to become less responsive to stuff that's going on. So we're not constantly getting startled. So the person may start to appear more flat and have more psychomotor retardation and symptoms of depression as it were due to fear conditioning. When a stressor is detected, though the stress response is exaggerated. The body's been holding on to all these excitatory neurochemicals and they found in people with Hypocortisolism, when their HPA axis is triggered, instead of what a normal HPA axis would do and say go 0 to 50, their HPA axis goes 0 to 200 and they become dysregulated really, really quickly. Which goes back to that research that I cited earlier about the dysregulation in the hypothalamus, the prefrontal cortex, as well as the amygdala. So we've talked about re experiencing and we've talked about hyper vigilance. Let's talk about avoidance. One of treatment goals for avoidance include helping people desensitize to overgeneralized cues. If they were a victim of a home invasion, for example, then they may feel that they are never safe when they are home alone. We want to help them desensitize to this and figure out what they need to do to take back their life. How can we empower you to feel safe staying at home? Maybe it starts out by staying at home for 30 minutes or staying at home during the day for 30 minutes and then gradually working up to when they can be home by themselves, you know, anytime and not be terrified. We want to encourage the addition of positive experiences. If they're experiencing a lot of hypocortisolism and anhedonia, then we want to help them experience positive things. They're not going to have the same emotional reaction that they would if they weren't experiencing hypocortisolism. But they can start feeling these little glimmers here and there, positivity, and help them develop distress tolerance and emotion regulation skills. So when they do experience a trigger and you know, if they go from 0 to 200 because they've got some hypocortisolism or some exaggerated startle response, that they can regulate that and they can tolerate that distress and get back into their wise mind more quickly. And instead of using up so much energy and so many excitatory chemicals on a particular incident, changes in beliefs make sense. The person needs order and meaning in life. We all want that. We're always trying to understand stuff. Changes in beliefs help people regain control and, and theoretically their ability to predict. Unfortunately, in trauma A lot of times this means trying to control too much and wanting to be able to predict everything. And that's just not how life works. Changes in beliefs can revolve around persistent and exaggerated negative beliefs or expectations about oneself, others, and the world. I am bad, or I am useless, or I am helpless. The way the person felt in that moment may be overgeneralized and contribute to their current state of dysphoria. They may feel out of control of everything in their life because they were out of control of that situation. They feel like they failed. They may feel like no one can be trusted. You know, if they were attacked by a friend or if they were attacked by a stranger, it doesn't really matter. Either way destroys trust. And then you go, well, who can I trust? Or the world is completely dangerous. You know, I don't know where I can go where I don't have to be on guard. So we want to help people really look at their beliefs and address those cognitive distortions that are all or nothing thinking or that are too personalized, etc. People often experience persistent fear, horror, anger, guilt and shame. So we want to look at the underlying cognitions that are prompting these fears. Understand them, understand again, just constantly ask yourself when you're talking with clients, how does this make sense from a survival perspective for this person in this situation? Trauma taps into nearly every basic fear. Loss of control. Whenever there's a trauma, we are out of control of the situation somehow, whether we're out of control of our own body or we're out of control of somebody else, or the weather or whatever it is, the unknown. When a trauma happens, generally we don't know how it's going to turn out. Death, am I going to die? I could have died or I was unable to prevent someone from dying can all play into it. Because when traumas happen, a lot of times death or violence is prominent. Isolation. Nobody will understand what I went through. And so I can't share with anybody or I don't want to burden anybody with this because they're going to think bad things about me. And trauma also taps into people's fear of failure. They feel like they failed themselves, they feel like they failed other people. They may feel like they have let other people down if, you know, and it could be even something like a person who got robbed in a parking garage may feel guilty and they may feel like a failure because they didn't protect themselves. They think, well, I should have, you know, done a roundhouse kick and kicked the gun out of the guy's. Hand. Well, that happens on tv. That doesn't happen to most people in real life, unless you're like a third don black belt. Helping people understand what they had control over is going to be really important. After a trauma, people's lives are changed forever. And that happens on a daily basis. Things happen that change your life forever. And, you know, sometimes it's for good, sometimes it's for bad. With trauma, it happens to be, at least initially, a little dip in the system, a little negative sort of thing. Some people, when they embrace the survivor mentality, if you will, use that trauma, yes, it's unfortunate. And they wouldn't wish it on their worst enemy however it happened. And this is how they're going to integrate it into the rest of their story. It's often necessary to grieve the loss not only of tangible things like property, but also existential things like belief in a just world and the goodness of people. We want to help people evaluate how their values and their beliefs have changed and examine, you know, where those are, what were they before the trauma, what are they now, and what do you want them to be? You know, what do you want? You can't go back to where it was most likely. But are your current beliefs too rigid? And it's important to help them figure out what beliefs feel comfortable for them. You may not agree, but it's what their feelings are. And then they need to grieve these things. Denial, anger, bargaining, depression, acceptance. They need to go through the stages and actually grieve the loss of all of these things. We need to help people identify the threats associated with the thoughts that the person had or is having. What is triggering your anxiety, your depression, your fear that you're not safe, and address those cognitive distortions using cognitive processing therapy in one, for one example. And yes, you're right, it is easy, unfortunately, for people to blame the victim. And it's really important that we put ourselves, we those who didn't experience it, put ourselves in the position of that person under that amount of stress. My husband was law enforcement for, you know, almost two decades, and we'll be watching movies and shows and stuff, and he will just sit there and talk about how somebody should have done this or why aren't they doing that, or da, da, da. And I'm like, not all of us are trained to react like that under stress. Sometimes when we are experiencing terror, we freeze. And we don't talk about that a lot. We talk about fight or flee. Well, there's fight, flee or freeze. Sometimes we Just freeze. And it's important to recognize that sometimes people just were not able to make their body move. They were literally paralyzed. And we don't want to blame them for choices that they made when they weren't clear headed. So challenging questions, what is the evidence for and against this belief? I have the belief that I will never feel safe in my house again. Okay, well let's look at the evidence for and against that. How long have you lived there? And you know, go through and start probing. Are the sources of this evidence reliable? You know, feeling based evidence is, you know, I walk into my house and I feel scared. Well, yeah, that makes sense because if that's where the trauma happened, you're going to feel scared. Now, is there evidence that right now in your house you are unsafe? Is there evidence supporting your fear? Encourage them to keep going back to fact based reasoning. Encourage them to examine whether they're basing their belief on the whole picture or a small aspect of it. You know, what else was going on that contributed to this situation? The person that was in the parking garage. You know, parking garages overall, you know, people use them every single day. A lot of times bad things don't happen. What else was going on in this situation? Okay, well it was two in the morning and I was carrying the cash bag to take to the bank and put in the overnight drop slot and I was by myself. Okay, well there's a lot of extenuating factors there, helping people recognize what is different about what happened during the trauma. Does my beliefs contain all or none terms I will never feel safe again? Yeah, that's pretty extreme. So we want to look at when have you felt safe in the past 24 hours? Where have you been? Or in the past before this happened, where did you feel safe, do you think? Can you envision yourself feeling safe there again? Maybe at your parents house or at your best friend's house or you know, start identifying certain places where the person might feel safe to find the exceptions. In what way is this belief confusing high probability and low probability events? Well, high probability is that somebody's going to rob you in the parking garage or break into your house again. How likely is it that that's actually going to happen? Increased arousal can lead to irritable or aggressive behavior, which makes sense when you're hyper vigilant, when you're, you know, think of that tennis analogy. When you're on your toes, when you're waiting, then when something happens, you're more likely to lash out. Makes sense. That's just kind of what we do when we are in hyper mode. That anger threat reaction is your body's desire to continue to self protect. Great. Thank you brain for not wanting to let me die. You know, that's awesome. Let's figure out how we can do this so we're more pleasant to be around. So help the person identify and address triggers for their irritability or their aggression. For some people it may be because they haven't got a good night of sleep since the trauma happened. For other people it may be environmental cues or sounds or people that are triggering aggression. For other people, the trauma was so overwhelming and they are so drained that they have no energy left to have that filter. To be patient with people. We want to look and say where's this irritability coming from and how can we help you address it? What can we do to help you get to the point where you can deal with life on life's terms? Help them develop skills to address emotional and behavioral dysregulation. We talked earlier about distress tolerance skills. Another acronym is Stop, Stop, Think, observe and participate. Encourage them to remember when they start feeling irritable, to stop, take a few deep breaths to slow their breathing down and to slow their heart rate down. And that will give them time to think, think, observe what's going on and then participate by choosing the best response that they have at that point in time. People may also engage in reckless or self destructive behavior to stop the pain, to distract or numb themselves from the pain, or sometimes to regain control. They may feel like, you know, this happened to me once, lightning doesn't strike twice, so I can do whatever the heck I want because I had my bad experience experience for this lifetime. And that's not exactly how it works. We do want to encourage people to look at the unhelpfulness of some of those reactions in terms of, you know, what is it that you want out of life and is reckless or self destructive behavior helping you get closer to that? Or is it just using a bunch of energy to try to help you avoid thinking about the trauma and just muddle through life? I don't want people unless they really want to. I don't want people to muddle through life. I want people to enjoy life, to embrace life, to, you know, go out and try to engage with life. And people who are experiencing PTSD just don't have that energy a lot of times, or if they do, they're kind of white knuckling it the whole time. Hyper vigilance is there because it protects us from A world that seems dangerous and unpredictable. We want to help people observe ways that they're safe. You know, let's look around and what do you need in order to feel safe in my office? What do you need in order to feel safe in your office? What do you need in order to feel safe when you're in the car? You know, break it down to specific places so people can start thinking, okay, these are the things that. These are the things that I need. You know, after the student murders, for the longest time when I would go running, I would carry pepper spray with me. That helped me feel safer. I still had my music on way too loud, but I would run during the daylight hours, etc. Those things helped me feel safe. Other symptoms? People may experience problems with concentration. Well, it makes sense. Hyper vigilance prevents filtering out extraneous stimuli. Think about a soldier in a foxhole. They're going to be hypervigilant. They're going to be alert to every sound, smell, sight, movement, whatever, because they don't want to be attacked in their foxhole. Well, that's what hypervigilance is. It's your body going, I can't filter out anything because I don't know where the threat may come from next. Makes sense. So if we address the hyper vigilance and help people start feeling safe, then their brain can go, okay, I can take a chill pill for a while. Intervention. Create places that are peaceful and safe for that person. And I've talked about that a lot in this presentation. Remember the mirrors so you can see things that are going on behind you. Try not to have your back to a door or a window, yada yada. Again, feng shui is really helpful with that. Meditation can also help reduce stress related reactivity. There are not, there isn't just one type of meditation. So explore the different types of meditation and episode 333 of Counselor Toolbox. I talked about a bunch of different types of meditation. Not everybody's going to want to close their eyes. That's okay. Not everybody's going to want to sit still. That's okay. There's a type of meditation out there for everybody. But meditation helps people learn to reduce that hyper vigilance and reduce stress reactivity so that they can focus and concentrate a little bit better. People who have difficulty falling or staying asleep or have restless sleep. Makes sense. You're vulnerable when you're asleep. You know, when you close your eyes, you don't know what you're gonna see when you wake up. If you've ever Seen the movie? Oh gosh, what was it? Psycho. You know, for the longest time I did not shut my eyes in the shower. I just, I wasn't gonna do it. Well, think about when you're asleep. Not only are do you have your eyes shut, but you also are just not aware of what's going on. So your brain doesn't like that. It says that's not a safe place to be. We want to help people figure out how they can feel safe so they can get that restorative sleep. They need to start feeling better because lack of sleep is going to trigger depression, thyroid dysfunction and a whole host of other problems. Create a safe sleeping space and the ability to easily reground. Wherever your sleeping space is, create it so it's safe for me. I have to be able to see all of the entrances and exits. Gotten to the point now where I can go to sleep without lights on. But it took me a really long time to get to that point where I didn't have to have a lot of light going on. Emotional support dogs can also be helpful for people who have difficulty sleeping because the dog wakes up before anybody else does. And you know, if you have that big boxer German shepherd or even that little rat dog that tries to eat paramedics or whatever, you know, those animals often make people feel more safe. And the exaggerated startle response, we've talked about this, I'm going to hit it again real quick. Think about how exhausting it is to go from 0 to 200 each time you're startled because of hyper vigilance. People with PTSD are aware of more things that may startle them and they may develop hypocortisolism. So it's important for them to develop tools to reduce vulnerability and increase energy reserves so they're getting enough sleep and they are in a safe environment so they're not constantly being overstimulated. Develop self talk scripts to de escalate when they do dysregulate. You know, to this day I tend to have a stronger startle response when somebody comes to the door and the dogs start to go nuts. But it's very, very, very short lived because I know what it is and I can, you know, I talk, it's just the ups man or whatever. But it's important for people to be able to feel like they have control. Increased arousal. The traumatic threat was unpredictable so the brain thinks future events may be unpredictable, therefore you're going to be more aroused. Increased arousal keeps people alert to potential threats. Using the challenging questions you can help clients examine their beliefs about the event and their current safety. Avoidance and numbing helps the person survive since nobody can be alert in pain for that long. We want to help people understand that during a traumatic event, certain chemicals in the body may prevent effective memory formation as a protective strategy. And numbing actually can help preserve precious energy. Changes in beliefs keep the person from feeling vulnerable again and may help the person try to make sense of what happened and integrate it into their schema and finally re experiencing. Like trying to fit a puzzle piece. The brain is trying to make sense of how this fits in to their schema. The brain may have to develop new schema based on likely faulty memories from the trauma. So many stimuli are overgeneralized and cause triggers for anxiety everywhere. So these faulty memories that every stranger is dangerous or I can never predict when something's going to happen. We want to help people, you know, look at the facts of the memories and reconceptualize those schema in order to feel safer and more empowered.