 Hi everybody and thank you for coming today. We are going to be discussing a strengths-based biopsychosocial approach to working with people with PTSD over the next 45 minutes or so. We're going to highlight the functional nature of most behaviors and reactions. One of the things that I found when working with patients with PTSD as well as, you know, just about any other diagnosis is the fact that they look at it as a pathology. They look at it as something that's broken when in reality, if you take a different approach to it, you can see how it may not be the best way of dealing with a situation, but it is a survival mechanism. So then we'll define PTSD, examine the function and meaning of PTSD symptoms, develop an understanding of why some people develop PTSD and others don't, and explore useful interventions for working with persons with PTSD. So it's important to remember that humans and animals experience reactions that prompt behavior. So when something happens and we perceive a threat, then our body sends out all those get-up-and-go chemicals and it tells us that we need to either fight or flee. It's a protective mechanism. It's saying there is danger for some reason and this danger can be real or it can be overgeneralized like maybe you're sitting in the living room and a cabinet bangs in the kitchen and you startle. Well, that startle response is natural. It says there's a threat and then your cognitive stuff kicks in and it goes, oh, that was just a cabinet, nothing to worry about. People with PTSD tend to be somewhat hypervigilant and the startle reaction may be overgeneralized. They may be more stressed out and more reactive to certain situations. These reactions, though, are designed to help people protect their own life. It says there's a threat and then how we deal with it is really what we want to work on with most of our patients. The other reactions that we get are designed to help people avoid punishment or achieve a reward. So this is not so much with PTSD. This is more with anything else that prompts a behavior. But it's important to remember that basically we have two reasons for doing something, protection and reward. PTSD, and this is one of my favorite topics, if you will, or pet topics, I focused my dissertation on it. Because PTSD normally we think about something that occurs to someone when they have a single or maybe a couple exposures to really traumatic events. But there's something called gradual onset PTSD, which is common among military personnel, law enforcement, and even sometimes emergency room doctors and people like that who are exposed to trauma and horror on a regular basis. I mean, things the rest of us probably wouldn't even dream of seeing. And they see it, you know, a couple times a month or more. There's also a gradual onset PTSD that has been associated with child neglect. Because if you think about it, a child who is two, three, four years old, if mom and dad aren't there, they disappear for days on end, that is perceived as a big threat because a two, three, four-year-old can't feed themselves. They can't take care of themselves. If mommy and daddy are fighting all the time and, you know, the people that are supposed to take care of them, there's a threat that they may disappear, that's very traumatic to a small child. So they've seen that some of the brain changes that we associate with post-traumatic stress happen among children who grow up in households where there's a lot of violence, where there's a lot of neglect. Traditional exposure to an event or multiple events can be like military if you're in combat and you kill somebody. I mean, that is a very defined event. Crime victims, people who are victims of rape, people who are victims of domestic violence. Gradual onset, we want to look at things like law enforcement. Can they be faced with a threat to their life? Can somebody point a gun at them? Sure. More often than not, though, with law enforcement officers, it's seeing amazingly horrific events day after day after day that eventually starts kind of changing their perception of the world. Military, not all military personnel are actual frontline combat type people. Maybe deployed, though. Think back to, I'm going to date myself here, the show MASH. Being in a medical unit that is kind of behind the front lines but still right up there and in harm's way produces a sense of threat. It's not a safe environment to be in. My uncle, you know, to this very day, you don't want to wake him up from a deep sleep because he wakes up swinging and that is kind of a throwback to his days in Vietnam. He wasn't ever in the front lines, but he was always hypervigilant when he slept. He didn't ever sleep well. Still doesn't. And child abuse and neglect, we already talked about. So I want you to kind of broaden your thoughts about what post-traumatic stress looks like and understand that it deals with people experiencing a sense of helplessness and that they can't really integrate with the way they see the world. It's out of context or it conflicts with some of their truly held beliefs. The definition is an exposure to a horrifying event in which there was a sense of helplessness and potentially a threat of loss of life. So each symptom that we're going to talk about, I want you to think about the function of the symptom. Why will the body do that? What is the function of it? How does it help the person survive? Or how does it help the person exist? What triggers that symptom or exacerbates it? So think about if you have a client with PTSD or just hypothetically you had a client who had PTSD and they had the symptom, what do you think would make it worse? Likewise, what could make it better? What might help them? And we're obviously going to ask them this in a strengths-based approach. We're going to say, you know, these flashbacks you're telling me about. What kind of things trigger your flashbacks and how can you prevent them? You know, sometimes you may feel like your flashbacks are a lot worse and you're having a lot more of them. What happens that sets that up where they're worse or more frequent? And when you do have a flashback, how do you deal with it in order to kind of keep control of what's going on? And then we want to hypothesize or theorize about other things a person could do in the midst of these symptoms because they may not have a real good grasp on what to do when some of these things happen. And I'll share with some of my experiences as we go through so you can kind of connect it with your clients. Re-experiencing the traumatic event through intrusive or upsetting memories of the event. Flashbacks, nightmares, feelings of intense distress when reminded, and intense physical panic reactions to the reminders of the event. Okay, so let's talk about memories. These can happen asleep or awake. So what is it that might bring about these memories? Are there smells? Are there sites? Are there situations? I've mentioned before that my stepfather lost his first family in a fire way back in the 60s. And you know, so Christmas time tends to exacerbate his upsetting memories. And yes, it's been a long time and he's learned to deal with them. But Christmas time, Christmas lights, seeing fires, especially house fires are extremely triggering for him. Other things, I worked with a law enforcement officer who had responded to a accident on the interstate and the truck driver was pinned in the semi. And the officer, you know, got up on the side and was trying to get this guy out. And eventually, long story short, the officer had to step down because the semi was fixed and to explode. And he watched this guy burn alive. So that being said, being on the interstate, being around semis, smelling gasoline, smelling smoke, there were certain smells that could trigger it. Helping him understand what the re-experiencing, what triggered the re-experiencing. So the next thing is to say, why? What's the purpose of re-experiencing this event? Well, for one, and you know, if you think back to Piaget, you can think about assimilation and accommodation. Whatever happened didn't fit with your worldview. I mean, that was just so out in left field that you would ever have to step away from somebody who was getting ready to die. Or, you know, that you would ever come home and this would be part of your life. So having to figure out how to integrate that is one reason why it may come up because it's not, you haven't made sense of it yet. The other reason we might look at it is to say that this situation did produce a huge sense of helplessness. And your brain says, you know, we really don't want to do that again. So if you smell this, this smell, it tells you that there's a potential for danger. And we don't want to go towards danger. We want to go away from danger. So you need to get out. So it's kind of a constant reminder of you need to protect yourself. Working with clients and cognitive processing therapy is very helpful with this, among other things. But helping clients be mindful of what is going on with them, helping them stay anchored in the present, and helping them make sense of what happened. And this is what we can do in counseling. This is kind of where our function kicks in. And how that situation, whatever it was, is different from now. Because that situation was awful. And I'm not going to take that away from them. I'm going to let them process that however they need to. And we're going to talk about that a little bit later. But I do want them to look at right now. The reaction that they're having, is it logical? You know, if they're on the interstate, and they're stuck behind a semi, and it's a traffic jam, and they start smelling exhaust fumes, is it a rational reaction to get in a panicky state? It takes time for people to learn to kind of counter condition some of these automatic thoughts. But helping them become aware. Nightmares is another huge one for a lot of people with PTSD. And when I ran a clinic, or a program in one of my clinics for veterans, they would often wake up in the middle of the night with these awful night terrors, and be disoriented to where they were. So talking about what makes the nightmares worse, you know, watching certain shows before bed, medications, lack of medications, alcohol, what is it that may make these nightmares become more vivid and more frequently, sometimes just stress can make that happen. But also having a plan in place for okay, if you wake up with a night terror, what can you do to mitigate this reaction? Sometimes you can create a nightmare if you go to bed and you're so afraid you're going to have a nightmare, you either A, may not sleep well, or B, you may kind of focus on it so much that you talk yourself into it. So one of the things that we would do with our patients that had the night terrors, they would always be able to have a nightlight in their room. So they could see they could get oriented visually as soon as they woke up. We would have them, you know, keep a light by their bed that they could turn on, we would have them make sure before they went to bed, they had relaxed and focused on something other than the trauma and other than worrying about having a nightmare. Obviously, the more stress they were under or if they happened to be dealing with this issue in group, in therapy at that point in time, we knew that that might bring it more to the surface. Being aware that okay, it might happen and how to deal with it cognitively was so helpful to a lot of people because they felt a little bit more in control, even if they did have a nightmare. When they woke up, they felt like they were able to kind of get back in contact with the immediate time and place a little easier. Symptoms of avoidance and emotional numbing, avoiding reminders of the trauma. Well, it makes sense. If something reminds you of the trauma, you're not going to want to go back and remember it because that was probably one of the most horrible days in your life. Totally makes sense. Now, if you start trying to avoid every single reminder and every reminder of a reminder and every reminder of a reminder of a reminder, then eventually you're not going to be able to go anywhere. We need to help people identify what these reminders mean and figure out how they can deal with them in a meaningful way. If a parent's child drowned in a swimming pool, horrible day, just extraordinarily traumatic, they can't avoid seeing water the rest of their life. So we need to say, okay, what is it that you're going to do to help you stay focused in the present? And we're going to deal with all the stuff around that situation, no doubt. But in the present, how can you handle it if you have to see a pool? If you see a advertisement online for people who build pools, anything that may trigger some of your symptoms, how can you deal with that? Inability to remember important aspects of the trauma. You know, this is a cool thing about our brains. If it's something that is too overwhelming, and obviously this is not, this is only my own opinion and my own observation from working with clients over the years, people don't always remember everything right away. But it seems like once they're strong enough, the brain kind of gives them a little bit and says, okay, you're strong enough, you can handle this much now. And you can handle this much now. And over time, they start to fill in the gaps. But it's almost like there's a floodgate there and somebody going, you can't handle everything. Encouraging patients to be kind to themselves, if they can't remember important aspects of the trauma, they will come. And if you've ever tried to think of a word, you know, it's right on the tip of your tongue, and the harder you try to think, the more frustrated you get. This is the way it is for a lot of people who can't remember all the aspects of a trauma. Two things can happen. They can get frustrated, which just increases the rumination on the PTSD symptoms and frustration and feelings of helplessness and all that negative stuff. Or they may inadvertently start to make up stuff to fill in the blanks. I would rather them be kind to themselves and go, okay, well, when I'm ready to remember, I'll remember. And that is really hard for a lot of people to kind of wrap their head around that they don't have to remember every aspect. I want them to stay focused in the present. I want them to tell me, how is this trauma affecting you right now? How is it impacting your daily life? And then, you know, the other aspects, the details may or may not be important in resolving the trauma. But let's focus on right now. And then as you feel stronger, as you feel happier, as your coping skills get stronger, then, you know, we may revisit it. Loss of interest in activities and life in general. If you are constantly hyper-vigilant, if you are constantly being reminded of the trauma, if you're stuck back at that awful day, at that awful time, yeah, it's going to be hard to be interested in other activities and enjoy life. There's going to be some depression there. Trauma by virtue of the fact that it doesn't fit with our schema about life. And trauma by virtue of the fact that it tends to take away power results in a grief process of some sort. And keeping that in the back of our mind is helpful in understanding and conceptualizing what's going on with clients. Feeling detached from others or emotionally numb. Well, if you've seen people die, if you have been threatened by other people, then, yeah, it makes sense that it's going to be, you don't want to feel, you don't want to connect too much. You may not want to feel at all because if you start feeling you may not be able to stop. Totally makes sense to me. Now, is that a way to live life? No, you know, but it totally makes sense when you're overwhelmed by this flood of emotions that you may want to turn that off for a little while because that was overwhelming. Encouraging clients to take it step at a time. And then a sense of a limited future. They saw something horrific. They were threatened with death or they saw somebody die. So yeah, they may start questioning how much longer am I going to live? You know, if I go outside, well, am I going to get hit by a car? Definitely thoughts that are going to go through people's heads. We want to focus on realistically. What is the probability that this is going to happen now? There may be a lot of things that happen. And they're at the forefront of your mind. And we call this the availability heuristic. Plane crashes, for example. We hear about plane crashes. And people are afraid to fly on planes because they think planes crash all the time. In reality, thousands, tens of thousands of planes fly every single day. But we don't hear about the ones that successfully land. We only hear about the ones that crash. And when you look up the statistics, it's more it's safer to fly than it is to drive and yada, yada, yada. Looking at the objective and the factual nature instead of, well, this is the thing that sticks out most in my mind. Therefore, it must be true. We need to work on addressing that cognitive fallacy. When we're working with people who are feeling emotionally numb, ask them, what do you do to try to enjoy life? What kind of makes you happy sometimes now? Or what would happen if you were happy? Survivors guilt is huge. Some people feel guilty for being happy. Some people feel guilty for going on with their lives because someone else lost theirs. Or someone else lost something. Working through that with the client is going to be important in recovery. Increased arousal, difficulty falling or staying asleep? Well, if you perceived helplessness, if you perceived a threat, even if you weren't asleep when you perceived that threat, guess what? Your body knows that when you're asleep, you're vulnerable. And you don't ever, ever want to be vulnerable again. It makes logical sense. You know, from a very primitive standpoint, it makes logical sense. So now we have to kick in our higher order thinking and go, all right, if I fall asleep, how likely is it that I am going to be traumatized again? Now there's a little caveat with that, because if people are also plagued by persistent nightmares, then not only are they worried about external threats, but they're worried about the threats in their dreams. We do need to pay attention to that and not minimize what sleep means to people and in what ways they may be vulnerable. It doesn't mean we can't deal with it. Helping them understand the function of increased arousal, helping them create an environment where they're safe, and helping them create an environment where if they do have a nightmare, they wake up and they can easily anchor themselves to the present time are all interventions that are pretty useful for people. A lot of patients that I've worked with with PTSD report that they can't just go in their room and lay down and go to sleep. They have to have the TV on and eventually they'll just kind of pass out. If they take that conscious time to try to shut their brain off, it goes to places they don't want it to go. Developing a good sleep routine and helping people identify what may be making them fearful of just turning out the lights and going to sleep will be helpful in the treatment process because we know that insufficient or poor quality sleep will lead to irritability and outbursts of anger. Now you've already got somebody who's wound tight. They're wound up, they're hypervigilant, whatever you want to call it, which is making it hard to fall asleep. And then when they start getting exhausted and they're still hypervigilant, irritability, anger, outbursts are just going to become more prominent because they're exhausted. They can't sleep, they can't relax, they're feeling helpless, they're feeling a little hopeless at this point. Don't blame them. I got that. So how can we work on this? How can we help you get the rest you need and the relaxation you need? And we can talk about exercise. We can talk about medication. We can talk about any variety of things that people think might help them be able to do the day to day things that most people take for granted, like sleep, concentrate. When you are hypervigilant, when you are aroused, when you are constantly on alert for a threat, you can't focus on one thing. You're scanning, you're constantly scanning. If you're not scanning with your eyes, you're scanning with your ears, you're constantly aware of what's going on. It's exhausting. So you have being exhausted when you're awake, then coupled with not being able to fall asleep, it's old after a while. And then this jumpiness and easily startled. When things go bump, when a car backfires, when somebody screams, whatever the trigger is for that person, it can start to be generalized. One of the things that we notice is that the more different whatever it was that startled you is than your current situation, the more of a startled response there is. So for example, if you are in the library and somebody drops a bunch of books on the floor and it makes a loud crash, you're probably going to jump three feet out of the chair. If you are in the middle of a busy restaurant and somebody drops, you know, a tray of glasses, likely the noise level in the restaurant was high enough and you were not so focused on whatever you were doing that is likely that your startled response is going to be lower. Helping people understand that that's just the brain's way of kind of letting you know that something just happened and there was a dramatic change can help people deal with this jumpiness. And there's a lot of other things we're going to talk about, but we're seeing that the brain is saying we're on alert, whatever this was, it was unexpected. So I don't know how to plan for it, which means I'm just going to stay on constant alert because I want to live. That's what it comes down to. Other common symptoms of PTSD, anger and irritability in general, guilt, shame or self-blame. This can be survivor's guilt or this can be guilt, you know, if you did something or the person thinks they did something that they were told not to do, maybe they were told not to drink and drive and they drank and drive drove and they ended up getting into a car accident and seriously injuring someone or killing someone or they were told not to talk to strangers and they talked to strangers and got kidnapped or they, you know, you can hypothesize and all the different oars you get the point. People may feel guilty because somehow they may feel that either whatever happened was their fault or they should have been able to prevent it or they should have been able, they should have been the one that died or got injured and the other person should have lived. Substance abuse, numb it out, try to make it go away. It's kind of like putting your fingers in your ears and saying na na na na na na na na. It numbs it, it doesn't fix it as soon as you start to sober up, it's still there. Depression and hopelessness, you're exhausted, you're hypervigilant all the time and you can't figure out how to make it stop. It can be exhausting which can lead to suicidal thoughts and feelings. The guilt, the shame, the self-blame coupled with hopelessness and helplessness can be overwhelming and at a certain point people may not feel like they can take it anymore, not a single another second. Feeling alienated and alone because a lot of people don't get it. They don't understand why this is still bothering you. They don't understand why you jump so high. They don't understand other things. Part of it is because with a lot of the patients I've worked with, it's because they haven't understood enough about the whys and the what's to be able to explain it. Once they understand it and they can explain it, then other people are generally pretty supportive. Feelings of mistrust and betrayal make sense. If whatever happened caused you to feel threatened, then you're either going to not trust yourself and not trust your own instincts and or you're not going to trust other people. That is a really depressing life to live in or place to be in when you can't trust anyone or anything. And then headache, stomachs, problems, and chest pain, panic attacks, anxiety, constant stress. It starts wearing on the body after a while and those neurochemicals start to get wonky. You know that's my favorite word. So why do some people develop PTSD and others don't? We don't know. That's the short version. Okay, class over. No kidding. Similarity to the victim or being the victim. Obviously if you're the victim, then you experience the helplessness or the horror. We've also seen that people who are similar to the victim, if a law enforcement officer responds to a call where a small child was beaten to death. If that law enforcement officer is also apparent, then it is meaningful and hurtful and devastating to them on a whole other way because they start seeing their child in that position. What would they do if it was their child? Unfortunately, that is a natural reaction for our brains to go to to go, oh, you know, I need to protect my child from anything like that ever happening. So if there's a similarity to the victim, people may internalize the trauma a little bit more. If it's closer to your safe zone, it's easier to say that something happens to those people over there. As it is, just then it is to say, this happened in my own neighborhood, or these people are just like me. That's scary. Because that means it's not us versus them. That means it's your part of us, which means you could be vulnerable. Social support after the trauma, if there is none, it's a problem. Most people within 24 hours, that's our key window, 48 on the outside, but 24 hours is when people are still have that raw nerve and can still articulate some of the things that are going on. They haven't started compartmentalizing and packing stuff up in the back of their mind. It's vital to have social support after the trauma. It doesn't mean and this is important. It doesn't mean that it's a time where somebody needs to go through every gory detail of what happened. That's not social support. Social support is somebody being there going, whatever you went through really, really sucked. And I'm here, you want to scream, scream, you want to cry, cry, you just want to sit, that's fine too. But I'm here to let you know that you're not alone and you're safe. If there's a history of mental health problems, if they already have a tendency to become depressed or have anxiety or if they have a history of PTSD or substance abuse, the likelihood of developing post traumatic stress symptoms, not being able to deal with this huge trauma is increased. And then the number of stressors in the past six months and in other presentations, we've talked about vulnerabilities. And this is really what we're looking at here. If somebody is already worn down, if somebody is already feeling a little out of control or a little disempowered, if somebody's already exhausted and they don't have the emotional energy to do much more than get up and kind of blindly go through the day, then when this happens, they may not have the energy reserved, they may not have it in them to respond as aggressively or as robustly as they may need to in order to prevent ongoing depression, anxiety and hypervigilance. So when we're assessing somebody with PTSD, ask them, you know, tell me about the situation. If you weren't the victim, how were you similar to the victim? Obviously, if they were the victim, that's the obvious place to start. How are people around you right now, similar to the perpetrators? What is it that you see in people? What is it you see in your environment that is similar to what happened? Because these may be triggers. These are things we can potentially counter condition. But I want to know what's triggering your symptoms right now. What was helpful for people to do after the trauma or what do you wish people would have done? This can give you an idea about how much social support they had and what kind of social support they want or need. And who can you rely on? Who can you rely on to do those things now? Who are your social supports? And if they say nobody, then obviously that's something that we probably need to look at. What can you do to take back your safe zones? And safe zones are really those places where you should feel comfortable, home, in the car, driving to and from work, going to the store, when you're at work. How can you take back those safe zones so you feel safe in those places? For example, going to the store at 11 o'clock at night and parking way out in the nether regions of the parking lot, probably not a way to take back a safe zone. Looking for a front parking lot, or even not going to the store at 11 o'clock at night. Those are common sense interventions to make sure that you stay safe, but also making sure that the environment is set up in a way that you feel safe, that you don't feel like you constantly have to listen for every creek, for every bang, for every footstep. How can you protect yourself from whatever it was that happened in the future? Sometimes this is just taking good safety precautions, maybe taking a self-defense class, maybe you could hypothesize and brainstorm with people, what is it that you need to do so you can feel empowered and safe? And then encouraging people to look at how the experience changed, how they view things. Do they now view the world as a scarier place? Do they now view certain situations or certain places as scary, threatening, undesirable? What is important to you now? Did that change? For some people, they'll say, well, my family is the utmost importance now. I need to focus on them. Some people have different changes in their priorities as a result of the trauma. And then how will you live your life now? And this is an open-ended, one of those sort of vague questions, to see kind of where they're going and where their head space is as far as whether they think they're safe, whether they still have hope, future directions, and get an idea about where they want to go from where they are right now. Sleep. We need to talk with people about sleep. If they're not sleeping well, there's going to be a problem because it balances their neurochemicals, helps to reduce cortisol and may improve adrenal fatigue. We know that when the central nervous system is constantly kind of on guard, the body gets exhausted. And you can only secrete adrenaline for so long before the body just goes, I need a break. I can't take it anymore. So people need to sleep. That way, their adrenals don't get fatigued. That way, they can respond to stress appropriately, yada, yada, yada. Adrenal fatigue leads to feelings of depression and anxiety. Helping people understand how something as simple as sleep can be negatively impacting them often has a big impact on their treatment. This is not brain surgery. There are very simple things they can do to start feeling better. Safety, environmental safety. Obviously, the common sense things like locking the doors at night and not going out, jogging on a dark path with nobody around at 11 o'clock at night, those are things that are important. But there are also situations where you feel more under stress. Law enforcement officers, you'll notice especially career law enforcement officers will never sit with their back to the door. You can kind of spot the cops in a room by how many guys are sitting with their back to the wall and looking at the door. That helps because you're not worried about who's coming up behind you. You're not on guard. Most of us, even if we are in a safe restaurant in a safe part of town with friends, we're a little bit more on guard when we can't see what's going on behind us or if somebody walks up closely behind us. Paying attention to that. Sleeping. Back to sleeping again. Research is found and Feng Shui will also tell you that you don't want to sleep with a window behind your head because then you can't see out the window. Feng Shui will say a lot of other reasons for it. But if you can't see one of the entrances or exits from your room it will likely add extra stress if you're already feeling anxious. Being able to see the door and see the windows, very helpful. Keeping a nightlight on if that helps you stay anchored. If that helps you feel a little bit more secure. Now we've talked before about the fact that the levels of melatonin go down the lighter your room is. So you don't want to have one of those 40 watt bulbs going all night long. Once your eyes adjust to the dark and when you're sleeping they adjust to the dark so when you wake up it won't be as big of a deal. A five watt bulb is more than enough. It's more than enough to illuminate the room so you can see pretty much everything around you. Anchoring. So when you wake up you can get in the present moment. What helps you stay anchored and this is helpful also with people who have dementia. If they can figure out where they are and when they are it's really helpful. Current pictures, lights, the ability to turn on a brighter light if the need arises. What else can help you stay focused in the present moment so you can see that you are in your safe bedroom. You're not in the middle of Afghanistan. You're not in the bedroom that you grew up in where you were constantly abused. What is it that can help you stay now? Some people need a safety item. You know I have a dog and actually I have multiple dogs but my dogs at least one of them sleeps in the room with me every night and that helps me feel safe when I go to sleep. Stimuli. Be aware of sounds, smells and sights that may help you sleep or that may get in the way of sleep. If you leave the TV on which is not recommended it could hinder your sleep because there are loud commercials. There are potentially cars backfiring online. There are potentially gunfights online. Who knows what you're going to hear when you're in that sleep state. You can turn on if you don't like sleeping in the ultimate quietness or maybe you're in a situation where you're not able to make it quiet. You live in an apartment complex or a busy city. White noise. You can get the apps for your iPhone. You can get the little devices that you put next to your bed where you hear jungle sounds, babbling brooks, whale calls, whatever does it for you. Something that can help you lull yourself to sleep. Smells. You want them to be not triggering smells. Things that make you happy. Things that make you calm. Not smells that remind you of the trauma or somewhere you don't want to be. And then sights. What can you see when you wake up? What do you see? What do you see when you're going to sleep? Remember when you were little or your children were little and they thought the boogeyman lived under the bed. Having them feel safe, part of that was a matter of checking the room, making sure that they had a night light sometimes, helping them feel safe so they could go to sleep. And then generally the boogeyman didn't rear its ugly head. Watching monsters ink before bed, not a good idea. Routine. Help people set a routine so their body knows when it's time to sleep and starts secreting melatonin. If they are laying in bed going, I really need to go to sleep. I'm afraid I'm going to have a nightmare. I really need to go to sleep. They're never going to get to sleep. So let's find ways to release stress and tension, get ready for bed, feel safe, and able to go to sleep. Finally, medication. Some people end up needing it, at least in the beginning, in order to calm down enough to sleep. And that's up to them and their doctor and, you know, whether they want to look at something like melatonin or they want to go with something like lunesta or maybe an atypical antipsychotic if they've got other symptoms going on. There are a host of options for medication, personal opinion. If that becomes something they rely on constantly to sleep, then there's probably some underlying stuff that needs to be dealt with. My goal is for people to live their highest quality of life possible. And some things that some people have seen, soldiers have seen, people who've been horrifically abused have seen. You know, I don't know that I'd ever be able to go to sleep with those memories in my head. So I am not going to say, well, you should only do medication for a short period. That's between them and their doctor and what's going to get them the highest quality of life. Encourage people to brainstorm different ways they can create safety at home. What makes them feel safe? I came home the other day and I don't remember where I'd been, but I had foolishly left one of the doors unlocked and nobody else was home. And I walked in now. Remember, I said, I've got four dogs. So the chances of anybody even going in there are slim to none, but I was still nervous. So we cleared the house. You know, I was like, all right, Brewster, come on, let's go. He's my big boxer and he sounds like he's going to eat you. And we went and we looked everywhere and in every closet and that made me feel comfortable. At that point, I, you know, I had locked the doors and I knew nobody else was in there and I was good. What is it that's going to help people feel safe? Hopefully, they won't have to clear their house every night. But, you know, if they have a dog, if they turn on the outside lights before they go to bed, if they, you know, and let them fill in the blanks. At night, I can't stand having the blind open at night. It just gives me this creepy feeling because I can't see out. That makes me feel hypervigilant and nervous. Other people, they don't really care. They have never had curtains because they lived in the country and, you know, I live in the country now, but I still don't want the deer seeing me walking around in my nightgown. How can they feel safe at night? What do they need to do differently when they're in the car locking the doors? What else can make people feel safe so they feel like they can get from one place to another without feeling threatened? Sometimes in the car, it's not just about somebody carjacking you, but it's about getting hit. It's about getting rear-ended. So, maybe not driving in high traffic times of the day, maybe taking back roads to get to and from work, whatever does it for people. And then at your office, how do you create safety? Not sitting with your back to the door? It's a good step. If you ever want to try this out, just spend, you know, 10 or 15 minutes with the door to your office open, sitting with your back to the door, and you'll see that you just kind of get a little uneasy when you don't know who's coming in and you can't prepare. If you have to have your back to the door, sometimes it happens, get one of those little reflective mirrors and put it on your computer monitor. That way you can see behind you. So, you're never surprised. People need non-judgmental social support that's available 24-7. When they're initially dealing with post-traumatic stress, it's important that they have somebody who can help them get grounded. Somebody that's empathetic and not judgmental. Not, well, you should be over this by now, or that happened over in Afghanistan. Why are you still letting it bother you now? Or you should feel this way, or you shouldn't feel this way. None of that is helpful. The person feels how they feel and they need to work through it. In the midst of a post-traumatic crisis, when somebody is really struggling, they may need some help meeting their health and safety needs. They may need some help remembering to bathe, getting to doctor's appointments. They may need somebody to sleep on their couch so they can get a couple hours' sleep and feel safe. That's okay. What is it that's going to help you and who can help you do it? Right after a trauma, and this is more acute stress disorder than PTSD, people aren't remembering much. And when people start PTSD treatment, if they start revisiting the trauma, or even just during the assessment talking about it, can throw them into enough of a tailspin that they're in a crisis situation. Write things down. Don't expect them to remember it. Don't say, I want you to do these three things before the next session and let them walk out. Write it down on a piece of paper so they have it and they can look at it when they get home. Some things you logically know aren't threatening still evoke a startle response. I talked about the cabinet banging. We have wood floors on the main floor of our house and four dogs. So I know good and well that it's going to be noisy once in a while, but if I am in the midst of working on a presentation and the house is dead silent and all of a sudden rain is sees a leaf blow by and starts barking, I usually jump. That's a startle response. Now I know it's no big deal, and I'm just like really, I've worked with clients who would get completely thrown off kilter as soon as they would get startled if someone would shut a door too loud. And then they would get frustrated that they got startled. And then they would get angry that they were frustrated and they just worked themselves up into a negative tizzy, if you will. Encourage people to acknowledge the event. The dog barked. Something must have blown by. Somebody slammed a door. Be kind to yourself. Don't get into that negative tizzy. Say, all right, I jumped, you know, no threat. Go back to what I was doing. Recognize the value of the startle response. It protected me. Now it may be a little bit over aggressive, but it did protect me. Identify times when your startle response might be greater, when you're tired, when you are in a really quiet environment, when you are in a stressful or in an environment where you perceive yourself to be unsafe. If I'm sitting in the middle of the police station, I am going to be a little jumpier probably than I am if I am sitting in the middle of the library. Understanding when you're on edge and when your startle response is going to be stronger. And then identify ways to mitigate it. When it happens, what do you do? How do you deal with it? How do you calm yourself down, slow your respiration, and get back to whatever you were doing? One thing that is very helpful with people with PTSD is cognitive processing therapy. And in your class, I've put a link to an online class by MCSU, I think. Middle South Carolina University, maybe. Anyway, it is an excellent class that walks you through a process of cognitive processing therapy. One of the tools that they use in CPT is called the challenging questions worksheet. And it says, alright, what happened? Right now, what happened? We're not talking about the trauma. What happened right now? Somebody slammed the door. What's the belief? What are those automatic thoughts or automatic beliefs that made you get upset? You got yourself all into a tizzy. Then we go into, is this belief based on facts? Is there objective evidence that you are under a threat or feelings? It brought up those feelings from the past. How reliable is the source? Are you a reliable resource right now? Or are you thinking with feeling focused? Are you, is your judgment clouded? Are you using extreme words like this always happens or I'm never safe? Is the belief based on only part of the picture? Nobody can ever be trusted because Tom betrayed me. Well, if Tom betrayed you, that's one person. So I don't think we can say nobody can ever be trusted. In what ways does this does this belief protect you because you're holding it for a reason? There's a rewarding factor to it somewhere. And generally, that's protection. And in what ways does this belief impair your life? Do you want to hold on to this extreme belief? Or is it keeping you from being happy and enjoying your life? And finally, how can you best use your energy? Are you going to use it to fuel this belief and make sure that nobody ever hurts you again? Or are you going to use it to deal with this particular aspect so you can enjoy all the other areas of your life? Most common cognitive errors and PTSD are overgeneralization, taking that car accident on the interstate and feeling like you can never be safe on any interstate or every semi truck is a potential threat. The control fallacy, thinking you could have controlled it, you could have fixed it, you should have been able to do something or thinking that you could have changed whatever it was. Taking responsibility, trying to think that in that situation, you did have power that you chose not to use. In reality, 99% of the time, there is nothing the person could have done differently. There is something they could do differently. Now maybe they may choose different courses of action. But a lot of times traumas are unpredictable. And there was nothing you could have really done to prepare for it. All or nothing thinking, catastrophizing, grandiosity, and personalization. It's all about me. It's all my fault. Everybody is, because this happened, everybody hates me, encouraging people to challenge these cognitive errors and figure out, you know, if everybody's upset, why is it? Is it all about you or not? You can't squeeze blood from a turnip. So we have to encourage people to take care of their stress levels and all other areas of their life. If they're working on their PTSD, if they're working on their trauma issues, that's where the lion share their energy is going to go right now. So they need to try to de-stress the other areas as much as possible. Therapy is a full-time job. You may only show up to counseling once a week, but therapy is a full-time job. So and I mean that for the clients, not for us. Of course, it's a full-time job for us. But they need to pay attention to their emotional health, their physical health, and they need to get some positive socialization. I said earlier that traumas necessitate some sort of a loss, loss of control, a loss of sense of safety, a loss of hope, a loss of idealism. Loss of life, obviously, there are those tangible losses. So we need to help people identify what they lost as a result of the grief or as a result of the trauma and how they can restructure that. Okay, they may have lost control over that particular situation. How can we reframe that so that's just situational instead of they have lost control over everything all the time? Once they get to you, they're probably out of the denial stage. So we need to look at the anger, the depression, and what does it look like to accept that this trauma happened? For each loss, ask people, what about this loss makes you angry? If you lost control, if you lost your hope, what makes you angry about that? How can you get your hope back or deal with it in a healthy way? This anger that you're feeling is protecting you from something. It's pushing people away, it's keeping you from being hurt again. What are you still protecting yourself from and how can you integrate that so you don't have to feel threatened all the time? And then remembering that depression signals a sense of hopelessness or helplessness. So if you've got all this anger going on and you feel like you need to be protected, yeah, you can feel kind of helpless. So let's look at what you can be hopeful about and where you feel empowered and how you can create the situation where you don't feel like you need to be protected all the time. How can you be empowered to take control back of your life and of your feelings? So PTSD can be from a single event or multiple ongoing stretchers. Traumatic events can change people's beliefs about the world in extreme ways. Instead of being totally safe and wonderful, it's a devastatingly scary place. For some people, understanding the function of the symptoms can help them desensitize because they understand that is their brain's reaction trying to protect them and then they can kick in their higher order thinking and say, you know, I'm not in danger right now. It can help them modify their beliefs about people, about things, about life and it can help them make positive, mindful choices so they're not vulnerable to PTSD stressors, PTSD reactions or PTSD triggers.