 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. So I want to welcome you to today's presentation on post-traumatic stress disorder, exploring the functional nature of symptoms. Basically what we're going to do today is pretty simple. We're going to review the PTSD symptoms and explore how do these symptoms make sense. And one of the reasons for doing that is because once clients understand why their brain might not be letting them remember stuff or why they're having this symptom, why they're re-experiencing, it makes sense. And, you know, they don't have to like it. And most of the time they aren't going to like it, but at least it makes sense. And they can say, okay, my brain is trying to remind me not to go into a situation like this again. And if I want these, the re-experiencing to stop, I need to figure out some way to sort of convince my brain that I've learned and this is not the same sort of situation at all. Because a lot of times, and we're going to talk about this more later, during the trauma, the stimuli, the triggers, the situation is over-generalized. So, for example, if you're in a traumatic event on the interstate, then any time you get on the interstate or any time even not on the interstate, you're near a semi-truck, for example, which reminds you of the interstate, it may trigger a flashback or some re-experiencing. Because the brain is going, okay, that reminds me about a danger time. I don't want you to go there, so I want you to remember. Once we help clients start understanding how their brain is trying to protect them, then they can kind of work with it to desensitize to a certain stimuli and to learn how to stay focused and grounded in the present. So, by understanding the function of symptoms, we can normalize the behavior. A lot of people with PTSD feel isolated, feel alone, feel like there's something wrong with them. And by helping them understand that really in a way it's kind of cool, the way our brain is trying to protect us and help us deal with this situation and make sure that we don't go there again because we want to survive, you know, that's kind of cool. It's unfortunate the way it's going about it right now. But if they can look at it from a curiosity, scientific sort of standpoint, unhooked from the frustration for a minute, it can help normalize the behavior and make them feel less weird, if you will. It can help them identify alternate ways to meet that same need or address the issue. So, again, if the brain is going, you were into that kind of situation before and it was not a good thing, it was really dangerous. We don't want to do that again. Our, you know, higher order thinking can override it and go, well, this is a similar situation, but it's really not the same at all. You know, this is, this plane is not going to crash. This, you know, I'm driving on the interstate, but it is not the same situation at all. So re-experiencing is the brain trying to replay it, figure out how to integrate it into your schema. And if you've ever done puzzles, I love puzzles. But, you know, you'll have the frame pieces are really easy because you know that the straight side goes out. And so it's easier to figure out where the pieces go. But then you get those weird shaped little pieces that all go in the center and fit together somehow. And if you think back to Piaget and assimilation and accommodation, this is kind of what your brain is trying to do. It's got this event here, which is kind of like a puzzle piece. And it's trying to figure out how to fit it into your current puzzle. And it may not fit at all. It may be from a whole different puzzle, which is part of the reason you keep going back to it. So think again about doing the puzzle. You take this piece and you turn it around and you turn it around. You're like, I think it should go there, but it's not. So I'm going to set it aside for right now. And then you do some more puzzle and you find another place where you think it might fit. So you bring it back. Same sort of thing with PTSD. The brain is trying to figure out how this fits in to your schema about the world, about interstates, about whatever. And the re-experiencing reminds the person of similar situations in order to protect them. Like I said, if maybe you were in a really bad car accident on the interstate. So anytime you get in a car, henceforth and forevermore, unless you deal with it, may trigger some sort of angst in your gut. It may trigger some re-experiencing. So in order to be able to live a high quality life, because in our society, we have to get in the car. I mean, it's just you can't avoid getting in some sort of transportation. We have to help the person figure out how to unhook those experiences from the majority of things. So those feelings are only associated with that traumatic experience. And maybe things that are like really similar. Maybe they were in a really bad car accident on a really rainy day during rush hour. Well, that you can avoid, avoiding getting in transportation ever. Probably not going to happen if you're going to have a high quality of life. So we want to help them make it more specific, less global. So they can enjoy their life. Avoidance, the system is already overtaxed. PTSD, we know that the person experienced a traumatic event. They are continuing to re-experiencing. Every time they re-experience it, that stress response system kicks off. So the system is exhausted. I mean, it's like being on high alert, not for hours on end, but for weeks or months on end. And the person is just exhausted. So avoidance is kind of the brain's way of helping the person avoid, couldn't find a different word, upsetting stimuli. And that could be it encourages them to withdraw from everything. So there's no chance of getting reminded of that traumatic stimulus or they could avoid things that remind them of it. Like for example, the car accident, they may avoid getting in vehicles. They may avoid doing anything that reminds them of that or being in places that remind them of that experience like the hospital or the doctor's office or wherever. Unfortunately, again, you can see where this can really inhibit somebody's quality of life. The other function of avoidance is it avoids unnecessary use of energy by not getting excited. You have some emotional flattening. People aren't as able to get excited about anything. And if you remember back to presentations from a couple weeks ago, that's how the stress response system works. You know, if you have that HPA axis activated enough, eventually the body's going to go, okay, continuing to exert effort and stay on high alert is going to do no good. So I'm going to not be reactive to the majority of stuff so I can conserve the energy for when there's a true honest to goodness threat. Which means people aren't able to experience happy excitement and pleasure and, you know, all the positive things we want to experience. They are just they're there and, you know, that's such a clinical term. I know, but so understanding that avoidance is, again, a protective mechanism. It's the body going, I got nothing left to give and I need to save whatever I do have left in case there is a really imminent threat. Changes in beliefs, again, makes sense before the trauma. The person may have seen the world one way, may have had beliefs about a just world, may have had beliefs about other people, may have had beliefs about themselves and their own behavior. And those beliefs may have been challenged or even contradicted, if you will, during the traumatic event. So now they've got to figure out, all right, I thought that I was safe in this neighborhood. I thought that I could walk to my car safely. I thought that people that didn't happen to people like me, whatever those beliefs are. And all of a sudden, those are all dashed to hell. And the person's going, OK, I don't know what to believe. I don't know where I'm safe. So this change in belief system, unfortunately, again, we're dealing with trauma, so things become much more dichotomous. You know, we were saying earlier that a lot of the stimuli are overgeneralized. So people are on high alert because a lot of things will trigger re-experiencing. Well, changes in beliefs can be the same way because they go from having a system that's working for them to really feeling like the rug was pulled out from under them and they don't know what to think anymore. So oftentimes, at least in early portions of PTSD, there are some pretty extreme changes in beliefs. And one of the things we're going to talk about with intervention is helping them challenge those beliefs and figure out which ones are accurate and what to do about them. You know, maybe it isn't safe to walk to your car at two in the morning by yourself. OK, you thought it was. You realize that that probably wasn't true now. So what can you do to mitigate that danger? So again, you can live a happy high quality of life. And changes in beliefs are ways that people try to assimilate the experience into their schema. Maybe they start going, well, maybe I deserved it. Maybe I'm not a good person. And that's why it happened. They're searching for meaning here. And they're changing their beliefs with all these maybes to try to figure out why we want to understand. And sometimes things are just inexplicable. And that doesn't make people feel real confident and happy. So we'll look at that in more in depth. And finally, increased arousal. Well, if this trauma came from out of the blue and whether you are in a car accident or a bank robbery or a home invasion or you're a soldier in Afghanistan, there are going to be traumas that happen that you may have known that something was a little wonky or you may not have. But nobody expects whatever it was to happen. So this increased arousal says you were down. You were sleeping on the job when this happened. And if you would have been more alert, maybe you could have protected yourself. Now, in reality, we know that's probably not true. But this is the brain going, you need to be more aware. You need to be hypervigilant. You need to be scanning for danger because we don't know where danger is going to come from at this point because it's just kind of all a jumble what happened. So let's start with re-experiencing. We re-experience things every day and we access schema that guide our actions. So when I go to work or when you go to work, you know, you re-experience, you get up and you do the same thing. You expect the same thing. You get in the car. You know, if it's going to be heavy traffic or not, that's all re-experiencing and you're guiding your day based on prior experiences. When you encounter a particularly volatile client and all of us have probably done that at one time or another, you know, we can learn from that prior experience. And some of that learning is going to get generalized correctly or incorrectly and that will guide our future actions. Think about approaching a stoplight and this is one of the more benign things. But based on your prior experience, if when you've approached a stoplight before, you've had enough time when it was yellow that if you gunned it, you could get through. Then that your brain will probably tell you, well, when you encounter a yellow light, you got time just gun it and you'll get through. Other people may be more cautious and when they've encountered a red light, they've slowed down because maybe they gunned it one time and they didn't make it and they actually went through a red light. So we learn from our past experiences and when we encounter that situation again, our brain draws from the database and it goes, all right, we've been here before, so this is what to expect and this is what you should do. In PTSD, you know, the context is over generalized often. So things, maybe a smell, because smell is one of our most potent triggers. Maybe there was a smell that was present during that particular trauma and you may be somewhere that's nothing like that particular trauma, but you smell that smell. And your brain kind of goes to this place expecting when we smell that smell, bad stuff's getting ready to happen. And the stress response system kicks off. Now, higher order thinking, we can say, you know, no, that's just the smell. This is an unpleasant thought. This is an unpleasant moment. Use some distress tolerance, emotion regulation, and get through it. But that takes becoming aware of the trigger and having the skills to basically talk ourselves down out of the stress response. For PTSD, like I said, a lot of times the precipitating factors are unknown. You don't really exactly know why this happened to you at this particular time. So if you don't know that, then you don't, you can't predict when or if it'll happen again, which contributes to the re-experiencing and the hypervigilance. So you're seeing where this is kind of making sense. Your brain's going, okay, there's, it's reminding me of this past situation. So you need to be on higher alert right now, just in case. And, you know, just in case you forgot, let me remind you of what it was like. And so it's trying to protect you. It's trying to remind you of the past, trying maybe to remind you that you need to get out of there. You know, you need to get the heck away so you can be safe. In many cases in traumas, the immediate resolution was not one of empowerment, which results in the person continually trying to figure out how not to be disempowered, how to never be in a situation where they're vulnerable again. And so again, the brain is going, this happened. And so you need to remember for this not to happen again, you need to remember to do all these things over here, which may or may not be accurate. And again, this is what some of the things we're going to talk about with clients in session about which things do you need to do. And which things, you know, might be unnecessary in the long run, and what tools can we use that will help you discern when there's a true situation. When people are re-experiencing things a lot. Once they learn to, I don't want to say discount, de-escalate the situation, they start re-experiencing, start having a flashback. They learn to get re-grounded, and then they start figuring out, okay, in this situation, because the brain learns from that too, in this particular situation, even though that smell was present, there was no threat. So eventually we will unhook or desensitize to a lot of the triggers in the environment, in environments that aren't threatening. But it takes time. Intrusive or distressing memories of the traumatic events can be demonstrated in children through repetitive play. And aspects of the traumatic event may be expressed, which can be really exhausting and traumatizing for parents. You know, children were traumatized, parents may feel responsible, may feel guilty. They may not understand why the child continues to replay this over and over again. And I would ask you to think about, you know, just for yourself, when something happens and it doesn't go right, you know, do you sometimes replay it in your head a few times in order to try to figure out what went wrong or what happened or to make sense of it. And I think most of us do. And this is what children are doing. It's not that they're trying to rub it in their parents' face or make their parents feel guilty. It's ever present in their mind and their mind's trying to figure out, what do I do with this? Recurrent distressing dreams in which the content or feeling of the dream is related to the events. Again, in children, there may be frightening dreams without recognizable content. It may be just they wake up with terrors. They may have dreams about bad monsters or something. And it doesn't have anything to do with whatever the trauma was, but the feeling associated with it, the terror associated with it is there. So again, let's think about what happens during dreams, what happens when we're sleeping. They theorize that our brain is taking the information that it gathered throughout the day and the stuff that was left over that was never dealt with, and trying to make sense of it and figuring out how to file it away, where it goes, where the puzzle pieces go in the puzzle of your life, if you will. And you know, the recurrent distressing dreams sometimes may be basically the brain going, I don't know what to do with this piece. I have no idea where to make it fit. And when you go to sleep, you know, that's still hanging there and I'm still trying to figure out what to do with it. It's not, the brain is not trying to traumatize you again, but it needs to make sense of what happened and get some sort of sense of empowerment control and resolution. And flashbacks or other dissociative reactions in which the individual feels or acts as if the traumatic events are recurring. And again, this is trauma specific reenactment in play with children. And if you've ever been in a situation that has been traumatic, you know, you've probably experienced a flashback. This is the brain's way again of saying, let's play through this movie again, and figure out if we can make sense of what's going on. You need to remember it so you stay safe. Now, assimilation, let me see if I can remember. Assimilation means changing the situation, changing that memory to fit into the puzzle. So it'd be taking that puzzle piece and a pair of scissors, and kind of cutting it to make sure it fits correctly. And assimilation is when you find a different puzzle and or you've, you know, you change your schema to fit the situation. But one way or another, this event has got to be integrated into the person's kind of psyche or schemas. And that's our job to help them figure out how to make that happen. Experiencing can be experienced as intense prolonged psychological or physiological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events. Now, you've got to remember where these cues are coming from because they can be everywhere. People who experience rape or sexual assault. I mean, think for a minute how often you hear about rape or sexual assault in the media in, you know, television shows, I mean, there's a whole special victims unit dedicated to nothing but that. So it's hard to get away from reminders of that kind of trauma. So what effect is that having on the person's psyche. The event represents a time in which the person experienced or witnessed something horrifying. You don't have to be the primary victim. Sometimes if you watch on with horror, it can be just as bad as if you were there. And depending on the age of the person, even seeing something on TV like when like 911. And then seeing it over and over and over again for a child or hurricane Katrina is extremely traumatizing because it seems to the child, even though we as adults know that this is the television replaying it because they need to keep the broadcasting going 24 seven hours a day. So in a child, it seems like it's going on continuously and it never stops. Imagine, you know, in somebody who's only had four or five years of life on this earth and experiences to see something like that and perceive it as continuing to occur and continuing to be terrifying, must that be? Because in a child's mind they're going, Well, why is this happening? And, you know, is it going to happen to me? Because there's no understanding of what's going on. So the brain's trying to help the protect the client, learn how to stay safe. And the purpose is to avoid a recurrence of pain or arousal of a recurrence of pain or arousal of the stress response system. So you do something that's traumatic, you know, maybe you're in a car wreck and you break your leg or you break your back. Of course that's going to be agonizing and you don't want to do that again. And the stress response, the terror that's associated with it. There's emotional pain and physical pain. There's emotional numbness and avoidance of people, places and activities that are reminders of the trauma makes sense. Why would you want to be reminded of that? When you look through your phone, when you look through your pictures, do you have pictures of bad days? No. You keep pictures of good days and you want to reflect upon that. So emotional numbness and avoidance is protective. Your brain's going, Yeah, we don't really want to go back there. That was pretty punishing. Another place where some people get hung up, if you will, or frustrated, which compounds what's going on, is their inability to remember the important aspects of the traumatic event. And if you remember back to last week, maybe the week before, we talked about how when people are in a state of trauma and that stress response system is going, when you've got high levels of the stress chemicals in the brain, it will block your ability to form memories and it keeps you from consolidating certain memories. And in a way, this can be protective because it keeps you from remembering some stuff. Now for people like me who are control freaks, that can be really frustrating because I was there and I want to remember it, gosh darn it. And so working with people and going, you know, there are bits and pieces of it there. It's kind of like somebody took a picture of the trauma and tore it into little bits. And scattered it across the room. And, you know, eventually you may be able to take the bits together and figure out what happened. But right now your brain says, it's more than I can, more than I can deal with. When I work with clients who have been in active addiction for many years, usually, they'll start doing their autobiography. And when they do it, I tell them leave extra space, only right on the front page of each page when you're doing your autobiography, because it'll be important to add to it later. And they look at me kind of quizzically. And for you who have heard this before forgive me. I had a mentor when I was doing my first practicum. And he shared with me this kind of analogy because my clients would get frustrated that they were coming to treatment and they were having to write their autobiography. But they'd been in treatment three or four times before why couldn't they just use one of their old autobiographies. And so Mark sat back very pensively. And he said, there once was a therapist in training and a supervisor. And this therapist wanted answers about something. And so the supervisor wouldn't give him answers. And the supervisor one day pulled out a picture of a fish and handed it to the therapist in training. And he said, go draw this and bring it back. And being dutiful, the therapist did not having any idea what they had to do with the price of cheese. But all right, brought it back, gave it to the supervisor. And the supervisor looked at it, put it in his desk, pulled out a picture of the same fish, handed it to the supervisor and said, go draw this and bring it back. Again, the supervisor did it. This went on three more times. And after the fifth time, the supervisor said, okay, I'm trying to wrap my head around this. But all I wanted to know is why can't they use their old autobiographies. And the supervisor pulled out all five drawings of the fish that the supervisor had done. And he said, look at these. And lo and behold, each time the supervisee had drawn that fish, he noticed different aspects. None of the five fish looked the same, even though he was drawing from the same template. So the takeaway message is our brain gives us access to things over time. We won't necessarily remember all the details at once. Which is why doing your autobiography repeatedly is not necessarily a bad thing, or at least leaving space to add to it. As the brain says, okay, we can start putting a few more of these pieces in because you can handle it now. The purpose of avoidance is the exhausted system conserves energy in case there's another threat. It's saying, you know, we can't get too happy right now. I don't want to get too angry or stressed out because I don't have much gas left in the tank. And I need to conserve what one energy I do have left in case there's another severe threat. And this is manifested as markedly diminished interest or participation in significant activities out of gas. Feelings of a detachment or estrangement from others. I don't have the energy for empathy right now, and you probably have no clue what's going on with me. So again, out of gas, don't have the energy and persistent inability to experience positive emotions. We need norepinephrine and glutamate in order to get focused, get excited, get motivated. We need excitatory neurochemicals for happy as well as stress. So understanding that if the brain's holding on to those excitatory neurochemicals, we're not going to feel up about much of anything, whether it be stressful or positive. So some of the things we can do is help clients understand that and instead of fighting with it, like trying to push against a house to move it, you're not going to move a house if you're pushing with your shoulder. It's just not going to happen. And you're not going to convince your brain to rebalance itself and let you have some excitatory neurotransmitters until it starts to rest and recover and rebalance and believe, if you will, that there's no stress that it's got to be prepared for. The world is not going to start falling apart. So for hypocortisolism, cortisol is your stress chemical after extreme stress or under chronic stress, the brain reduces the responsiveness of the stress response system, partly by reducing cortisol. This is protective. It keeps the organism from getting excited and using precious resources. And a lot of it is due to the fear conditioning so when a stressor is detected, the stress response is exaggerated. They're flat, they're flat, they're flat, they detect a stressor and all of a sudden they are off the charts, stressed out, excited, angry, whatever, they're just like zero to 100. It's important to understand that because helping clients learn to stress tolerance skills and emotion regulation can help them stop going from zero to 100. They can start working to control that stress response when they are startled because they're going potentially going to remain hypervigilant for a little while. So learning how to mitigate that stress response is going to be important in working toward helping the brain get rebalanced. Which is in beliefs. We all need to find order, you know, you go back through any of our psychological texts, you'll find different theorists talking about our search for order and meaning, and, you know, Victor Frankel from, you know, for one of them. We need to understand why we need to be able to predict that's just kind of part of how we're wired. So a persistent and exaggerated negative belief or expectation about oneself, the others or the world, maybe one way we're trying to regain order and make sense. And, you know, think again about that puzzle piece and this is the scissors. We're trying to make that fit and we're trying to understand why us, why did we experience that why now why in the situation. Sometimes people start going well maybe I was bad, maybe I brought it on myself. Maybe it's that nobody can be trusted. Now you hear how these are global stable interpretations. So we know that global stable negative interpretations are going to be stressful. We'll start with I'm bad. Most people in my belief are good. So, but I'm not going to tell the client well no you're wrong you're good, because that would be invalidating, but I would challenge them to find and we're going to look at that in a minute on how to do that. I would challenge them on on finding support finding evidence to support their thought that they are bad. Yeah, maybe they made some mistakes, but did they deserve whatever happened because of the mistake they made. No one, you know, extreme wording can be trusted. Well that kind of sets you up for a really really scary isolated life. So again, let's look at challenging those cognitive distortions or unhelpful beliefs, and the world is completely dangerous. Yes, there are some dangerous aspects to life. There are some dangerous people out there. I would argue that the world as a whole all the time is completely dangerous. I mean that tells me to go into my storm shelter shut the door and never come out. And again, that's not a quality of life. So let's look at how can you mitigate danger. Yes, there are some dangerous situations. How can you prevent getting in some of those situations. And as a result of all this may have some persistent distorted blame of self or others about the cause or consequence of the traumatic events. A lot of people with PTSD have a certain amount of self blame. And we're going to look at a song later that helps you kind of get into the mind of somebody who's struggling with the turmoil as a result of traumatic experiences. Persistent changes in belief, persistent fear, horror, anger, guilt, shame. Now fear and horror are our are our flea feelings, anger, guilt and shame are all kind of anger sort of fight feelings. If you want to look at them that way. But we're talking about fight or flee. We're talking about self protection. Trauma taps into nearly every basic fear loss of control if you're in a traumatic situation, you're looking on or experiencing it with helplessness and horror. The unknown, most of the time when you're in a traumatic situation you have no idea how it's going to resolve. It may involve, you know, possibly dying or inability to prevent someone else from dying. It could involve isolation, you know, not being able to access people that could help. And it also can make people feel like failures if they were unable to help themselves out of the situation, or maybe they start thinking that because of something bad they did, they deserved this somehow they failed in life. So when you're listening to people recount their trauma narrative. And I always use the word narrative not story because story implies something false. But when they're recounting their narrative, listen for themes of their basic fears, because in any of these child abuse car accident drowning robbery rape war. All of these fears are tapped into so it's not a wonder. People are feeling this threat response. Helping people understand what parts of the situation, or leading up to the situation or the resolution of the situation tapped into their fears and addressing those fears and the cognition supporting them will help them start to resolve their trauma. After trauma people's lives are changed forever, you know, it just that's the way it is. And it doesn't but it doesn't have to be changed for the negative some people can write a survivor story, and people can be resilient from trauma. It's often necessary to grieve the loss not only a tangible things like property, but also existential things like belief in a just world and the goodness of people. So as you're listening to their narrative, listen for things that they lost things that are changed forever that they can never go back and think this is a safe place again or they can never think a particular way again. Things like innocence being lost. There are a lot of existential things that they may need to grieve so going through that grief process, the whole denial anger bargaining depression acceptance, helping to work through it and figure out how to move to the next step. Identifying the threats and associated thoughts, the person had or is having that are supporting their beliefs and addressing any distortions or unhelpful bots using cognitive processing therapy and we've talked about CPT before. The CPT worksheet, you know, kind of cutting through all of the CPT theory and just going to the challenging questions worksheet and I encourage you to. There are some free CEUs on CPT from one of the universities and I'll look at that up at the end of the class. But I encourage you to go through that class, even if you can't get the CEUs for it because it's self study. It's a great class for learning another tool to work with survivors of trauma, but basically the challenging questions worksheet and I use this in a lot of situations. If the person says, for example, I'm a bad person. Okay. What is the evidence for and against this belief. Let's just start writing it down. Are the sources of this evidence reliable. And we're not always the most reliable sources of evidence for our own beliefs. So I would encourage people to look for external sources of information. But we can brainstorm what what is the evidence and maybe if they say I'm a bad person, I would say, well, what is a bad person look like or what is it about you that makes you a bad person. So I know what evidence we're looking for so we can try to find stuff to support it, but also to unsupport it. So understanding based on facts or feelings. And with a lot of trauma survivors. The reasoning is based on feelings. I feel like I am a bad person I feel like I must have deserved it. Therefore I must have deserved it. I don't know why, but I feel that way. So we want to talk about the difference between facts and feelings. So maybe based on habit or facts and habits can be persistent negative interpretations or old tapes that have never been checked. So maybe this happens and they suddenly start hearing their abusive parent in the back of their head going, I told you you were never going to be good enough and you were just the black sheep of the family and all kinds of hateful things. If an event supports what they were saying, then those thoughts are going to come back and they're going to be validated, and they're going to draw a connection, even if there really was is no connection. So we want to say is this belief really based on current facts, or just things that you always told yourself about not being good enough or, you know, deserving bad things to happen to you. I'm missing my belief on the whole picture, or a small aspect of it. And, you know, sometimes there's a lot more going on. It's not just about what that person did. It's about, you know, let's take a bank robbery, for example. It's not just about what that person did who happened to be there during the bank robbery. It's about the bank robbery security. It's about the bank not being alert to the joint being cased. You know, all kinds of the bank robbers themselves and why they chose to do that is not necessarily just about the person. So we need to look at the whole picture. Yes, this happened to you and you happen to be in the bank, but 6065 other people were in the bank too. So let's look at the bigger picture and see if we can't get a different perspective on it. Does the belief contain all or none terms like nobody is ever safe anywhere. You know, we want to look at that and see is that true or are there places that you can be safe, because I want my clients to feel safe somewhere. So I want to start identifying what are those places that you can feel safe right now. And how can you make some places that you have to be feel safe. So maybe having an office where you face the door so you're in the power position and you can see people coming and going all the time. That can help people feel safer. And in what ways is this belief remember we're still on the I'm a bad person. In what ways is this belief confusing high probability and low probability events. But they're saying I'm a bad person, we want to look at, you know, we all make mistakes, and we occasionally do bad things, but is the probability is the majority of the stuff that you do bad, or have you made some mistakes in your life. And is the likelihood of this happening again. High probability or low probability. I encourage them to go through each thought that is keeping them stuck and challenge it, and they may not come to the resolution that you really want right away and that's okay. Encourage them to keep challenging their beliefs and examining them as they as the beliefs come up and see if, because each time that same belief comes up, they can challenge it, and it may change just a little bit. Okay, then the next time it comes up it may change just a little bit more, and a little bit more and a little bit more so we're hoping for progress, not sudden epiphanies increased arousal, irritable or aggressive behavior well duh. If your brain is going I don't know where that threat came from but I never ever want to feel that way again so we are going to be hyper vigilant we are going to be scanning we are going to be aware. Some time before where you have been, you know, amped up for something you've been really really stressed for some reason. And somebody came up and made a loud noise behind you or tapped you on the shoulder and you jumped like six feet into the air I'm exaggerating of course. It makes sense. The fact that you have increased arousal, you know, demonstrates the fact that you want to survive, but demonstrates the fact that there's something still going on that you don't feel safe so how can we help you feel safe. Identifying and addressing triggers for irritability and aggression. I worked with one client whose best friend committed suicide with a gun right in front of him. So anytime he hears a car backfire, or a cabinet door slam or something that even vaguely remember resembles a gunshot. It throws him back into re experiencing, and he gets very tense and irritable. So identifying what those triggers are. So then you can start to desensitize them and developing skills to address the emotional and behavioral dysregulation when the triggers occur, and I call them stop behaviors. Stop, of course, you want the person to just, okay, let me take a breath. Think, am I in danger right now? You know, am I okay kind of get grounded real quick to a scan. Alright, observe what's going on. And this is where your mindfulness and re grounding comes in, have them observe four things they see three things they hear two things they smell one thing they can feel. We're trying to get that adrenaline to go down, we're trying to get them re grounded in the present moment, and not back in the original trauma. So once all that's occurred, they can participate and they can go okay, so I'm safe in this situation, but I'm a little jumpy right now so what can I do to improve the next moment. So I don't feel like I have to be on edge. Reckless or destructive behavior. Again, it makes sense. They want to stop the pain. Some people will start, you know racing cars or bungee jumping or, you know, abusing all kinds of drugs. They don't care if they die, because there's so much pain there's so much turmoil there's so much. I mean, being on and being hyper aroused all the time is exhausting and it's really stressful. And so they need to make the pain stop. And so they may participate in activities that they're already aroused, but that increases the dopamine there's a rush that goes with it. So at least if they're going to be hyped up they're hyped up and happy, or they're numb. Distracting, they can numb through whatever's going on they can distract themselves through thrill type activities again. A lot of times it has to do with reckless self destructive stuff. And sometimes they do things like trying to regain control saying, well lightning doesn't strike twice so I'm going to replay that trauma narrative, and I'm going to come out victorious this time. And that's not something we want them to do, but we know from the literature and from clinical experience that people will sometimes sort of replay that same situation in a different setting in order to try to come out victorious and not be defeated. And so we want to look at what was the motivation behind your behavior. When that happened. Exaggerated startle response that goes with that hyper cortisolism it's totally biologically explainable. Because the body's holding on to holding on to that energy in case there's a stressor, but when there's a stressor it goes from zero to 100. So we want the client to understand the brain changes and chemical changes that are going on right now, and help them develop the tools to reduce vulnerabilities, so they can increase their energy reserves. It takes time, but as they start desensitizing, and they're not getting triggered by so much stuff they're not getting triggered as often. They're going to start feeling safer, they're going to start feeling more empowered and this is where we want to go we want empowerment we want resilience. And we want them to start figuring out how to live the life they want to live and we can help them write the next chapter of their survival survival narrative in treatment. Hyper vigilance protects the person because the world is dangerous and unpredictable. And it can come out, you know this increased arousal problems with concentration. If you're aroused if you're on edge if you're on high alert, and you're sitting in a cafe trying to study for example, you're on high alert, then you're watching and paying attention to everybody that walks by. If you're not able to sound, you're not able to focus on what it is, but even at your own house, even in a place that's sort of safe, if you're hyper vigilant you're still hearing every time the floor creaks, you're still hearing every time the dog rolls over on the couch, you're still hearing all those things and it's distracting you. So it makes it hard to concentrate. There's one quick intervention or quicker intervention that people can do sort of right away. Again, I encourage them to create a safe place in their house, where they feel calm, where you know, maybe it's a place in the house that doesn't have any windows or only has one window, so they can see all entrances and exits. As a survivor myself, when I sleep at night, I need to be, even though I've got my eyes closed and it's dark, when I open my eyes, I need to be able to see the window in the door. If I can't, I have a hard time sleeping peacefully because I feel vulnerable. So I encourage people to create places in their house and in their work environment, if they can, where they can feel secure and and you know they can have pictures they can have whatever it is that will help them feel more secure. Difficulty falling asleep or staying asleep or restless sleep. When you're on edge when you're hypervigilant, your body is not going to let you get deep quality sleep. It's keeping you alert. It's like sleeping in a war zone, if you will. So you want to create a safe sleeping space and the ability to re ground when you wake up. When I worked with veterans, we had a one of our residential programs we had veterans with co occurring disorders. Many of them had night terrors. So we started allowing them to have nightlights, not really bright ones, but nightlights in the sleeping rooms. So when they woke up, they could quickly see their environment see their surroundings and get re grounded and start working through those mindfulness grounding activities to help them get out of that terror flashback state that they were in. When possible, emotional support dogs can be really helpful with hypervigilance and hyper arousal because they feel like like they've got somebody on their six, somebody watching their back. And dogs can also be very alert. Some dogs, you know, obviously have to find the right one, but some dogs are very alert to even the most minute changes in stress or energy level, and they will alert people, which is really good. My Brewster is really good about that. If I get even the slightest bit irritable or cranky and it can be about anything. He just like loses his little puppy mind. And I, I'm not like freaking out. I'm just a little perturbed about something. And he senses it. None of the, none of the humans sense it, but he senses it and he starts going crazy and have to tell him it's okay. But emotional support dogs can be helpful and can be a good source of sort of biofeedback. So final thoughts, tormenting thoughts and feelings and attempts to stop or avoid those thoughts and feelings are central to PTSD. We're going to go through the first verse and a half, I guess, of a song called the wrong side of heaven by five finger death punch. And the artist really talks about this torment. And because of copyright stuff, I can't play it, but I would encourage you to listen to it on on YouTube. It's got an excellent video that talks about homeless veterans and PTSD and all that kind of stuff. Anyhow, I want you to imagine while we go through the next two slides, you've been in a situation in which you had to kill to protect others. You had to or and or you had to let somebody die to protect yourself and be there for your kids or family. And the client that I worked with who was a police officer, and he was working a crash. A trucker was stuck in the cab of his semi and the semi was getting ready to blow the officer continually tried to get the guy out but eventually had to step down and back up, because he couldn't get the guy out from the cab of the semi before it blew up so we watched this guy burn to death. And it was extraordinarily traumatic, because he had to make the choice to let this man die. So in the song it says I spoke to God today and she said that she's ashamed. What have I done, what have I done, what have I become. She's basically saying I did some awful things in the spirit of what I thought was right, but you know it's not what my God wanted me to do. Then he says I spoke to the devil today and he swears he's not to blame, and I understood because I feel the same. So he's saying I'm not saying the devil made me do it. I chose to do what I did but at what cost. He's wide open I stand alone I'm no hero and I'm not made of stone. And so he's talking about feeling totally isolated and not believing that people could understand or do understand the choices he made, and he didn't do it to be a hero he didn't do it to get praise. He did it because he thought it was what was right, but he's tormented by what he felt he had to do for what he felt was right. He's wrong I can hardly tell. So again, he can't discern whether what he did was right or wrong. He's on the wrong side of heaven. He doesn't feel like he deserves to go to heaven, but the righteous side of hell. He didn't feel like he did what he did out of malice. He felt like he did it for the right reasons. I heard God, I heard from God today and she sounded just like me. What have I done, what have I become. I talk, believe and pray about doing things for the right reasons is kind of what he's saying. You know, God wants us to protect others and I was trying to do that but you know maybe my choices weren't the right ones. And then he says I saw the devil today and he looked a lot like me. I looked away and I turned away. So again he's comparing himself to the devil saying like the devil I've done a lot of things I don't know if I can forgive myself for and I'm not sure if I deserve forgiveness. I can't stand to see the potential for evil in my life. So he turns away. So he sees that he did evil awful things. But he's saying that you know he really did do them with the right intention in his heart and he's tormented by the memories and trying to figure out if he did what he should have done. And when we're working with survivors of trauma, sometimes they may be tormented by some of the choices they made in the middle of the trauma, or some of the choices they made that contributed to the trauma. So trying to put yourself in that torment and understand where they're coming from and how everything is confusing can be really helpful in working with clients like this. And, you know, I'll be honest every time I watch the video I end up boohoo crying so if you're one who tends to be emotional, don't watch the video to left to work. So increased arousal. The traumatic threat was unpredictable and future events are therefore unpredictable. You know, I don't know if I'm going to be traumatized again. I don't know how I can never feel safe again. So we want to help them figure out how to feel safe increased arousal keeps people alert potential threats. By using the challenging questions worksheet we can help clients examine their beliefs about the event and their current safety to see if they're really in as dangerous of a situation as they feel they are. Avoidance and numbing help the person survive since nobody can be alert and agonizing continuously for a long period of time. We want to help the person understand that during a traumatic event certain chemicals in the body prevent effective memory formation and this was protective. It's not that they're trying to make up something and numbing helps preserve their precious energy Changes in beliefs keep the person from being vulnerable vulnerable again and is the way a person tries to make sense of it. So we want to help them examine how they're changing their beliefs and which beliefs are changing. And finally re experiencing is like trying to fit a puzzle piece the brain is trying to make sense of how it fits into the current schema. The brain may have to develop new schema based on memories from the trauma because so many stimuli are over generalized and triggers for anxiety everywhere. So we need to help pare down and help the brain figure out what's dangerous and what's safe with this new information. Okay, let me see. This book. Now this presentation was not at all based on this book, but this book crisis intervention, promoting resilience and resolution in traumatic times. Love this book for working with trauma survivors and helping them create a resilience narrative. I do have a video on it on our YouTube channel that is, I believe it's called crisis resolution and resilience or something like that. So if you're interested in other techniques for working with crisis survivors. That is one of the first places I would start. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com slash counselor toolbox. This episode has been brought to you in part by allCEUs.com providing 24 seven multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. You can use coupon code counselor toolbox to get a 20% discount off your order this month.