PTSD stands for post-traumatic stress disorder a condition officially recognized in 1980 to describe exposure to a relatively brief but devastating event typically a war a rape an accident or a terrorist incident complex PTSD recognized in 1994 describes exposure to something equally devastating but over a very long time normally the first 15 years of life emotional neglect humiliation bullying disrupted attachment violence and anger a lot of us as many as 20 percent are wandering the world as undiagnosed sufferers of complex PTSD we know that all isn't well but we don't have a term to capture the problem we don't connect up our ailments and we have no clue who to seek out or what sort of treatment might help so here are 12 leading symptoms of complex PTSD we might think about which ones if any apply to us and more than seven might be a warning sign worth listening to firstly a feeling that nothing is safe wherever we are we have an apprehension that something awful is about to happen we are in a state of hyper vigilance the catastrophe we expect often involves a sudden fall from grace we will behold away from current circumstances and humiliated perhaps put in prison and denied all access to anything kind or positive we won't necessarily be killed but to all intents our life will be over people may try to reassure us through logic that reality won't ever be that bad but logic doesn't help we're in the grip of an illness we aren't just a bit confused secondly we can never relax this shows up in our body we're permanently tense or rigid we have trouble with being touched perhaps in particular areas of the body the idea of doing yoga or meditation or breathing exercises these things aren't just not appealing they may be positively revolting we may call them hippie with a snare and deeper down they are of course terrifying probably our bowels are troubled too our anxiety has a direct link to our digestive system thirdly we can't ever really sleep and we wake up very early generally in a state of high alarm as though during rest we've let down our guard and are now in even greater danger than usual fourthly we have deepened ourselves an appalling self-image we hate who we are we think we're ugly monstrous repulsive we think we're awful possibly the most awful person in the world our sexuality is especially perturbed we feel predatory sickening shameful fifthly we're often drawn to highly unavailable people we tell ourselves we hate needy people but what we really hate are people who might be too available for us we make a beeline for people who are disengaged won't want warmth from us and who might be struggling with their own undiagnosed issues around avoidance sixthly we are sickened by people who want to be cozy with us we call these people puppy revolting or desperate seventh we are prone to losing our temper very badly sometimes with other people more often just with ourselves we aren't so much angry as very very worried worried that everything is about to become very awful again we are shouting because we're terrified we look mean we are in fact defenseless eighth we are highly paranoid it's not that we expect other people will poison us or follow us down the street we just suspect that other people will be hostile to us and will be looking out for opportunities to crush and humiliate us we can be mesmerically drawn to examples of this happening on social media the unkindest and most arbitrary environment which anyone with complex PTSD easily confuses with the whole world chiefly because it operates like their world randomly and very meanly ninth we find other people so dangerous and worrying that being alone has huge attractions we might like to go and live under a rock forever in some moods we associate Bliss with not having to see anyone again how a tenth we don't register to ourselves as suicidal but the truth is that we find living so exhausting and often so unpleasant we do sometimes long not to have to exist anymore 11.
We can't afford to show much spontaneity we're rigid about our routines everything may need to be exactly so as an attempt to ward off looming chaos we may clean a lot sudden changes of plan can feel indistinguishable from the ultimate downfall we dread 12. in a bid to try to find safety we may throw ourselves into work amassing money Fame honor Prestige but of course this never works the sense of danger and self-disgust is coming from so deep within we can never reach a sense of safety externally a million people can be cheering but one jeer will be enough once again to evoke the self-disgust we have left unaddressed inside breaks from work can feel especially worrying retirement and holidays create unique difficulties those are the symptoms so what is the cure for all these arduous symptoms of complex PTSD partly we need to courageously realize that we have come through something terrible that we haven't until now properly digested because we haven't had a kind stable environment in which to do so we are a little wonky because long ago the situation was genuinely awful when we were small someone made us feel extremely unsafe even though they might have been our parent we were made to think that nothing about who we were was acceptable in the name of being brave we had to endure some very difficult separations perhaps repeated over years no one reassured us of our worth we were judged with intolerable harshness the damage may have been very obvious but more typically it might have unfolded in objectively innocent circumstances a casual visitor might never have noticed there might have been a narrative which lingers still that we were part of a happy family one of the great discoveries of researchers in complex PTSD is that emotional neglect with an outwardly High achieving families can be as damaging as active violence in obviously deprived ones if any of this Rings Bells we should stop being brave we should allow ourselves to feel compassion for who we were that might not be easy given how hard we tend to be with ourselves the next step is to try to identify a therapist or counselor trained in how to handle complex PTSD that may well be someone trained specifically in dealing with trauma which involves directing enormous amounts of compassion towards one's younger self in order to have the courage to face the trauma and recognize its impact on one's life rather touchingly and simply the root cause of complex PTSD is an absence of love and the cure for it follows the same path we need to relearn to love someone we very unfairly hate beyond measure ourselves the School of Life offers online Psychotherapy to people all around the world our therapists are highly trained and accredited and are a vital source of kindness Solace and wisdom for life's most difficult moments click the link to find out more
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There is a real threat here, in which case,
there’s a different intervention that needs to happen in order
to, to ensure one’s safety, right, but I think that is
really key. We do not want to fall into the trap of weighing
in and saying, This is no big deal. Just get over it. That is
problematic if there is a true threat and it is very
problematic, even if there is not a true threat, right,
because it’s also super invalidating for people who are
like, actually, this is really hard for me, right? So either
way, that’s problematic for us to say, this is no big deal.
This isn’t a problem. We want to – our goal is to help them
evaluate the situation and really pull in more evidence. Kendra Read: One of the things
that Jen noted earlier is that youth and actually people with
problematic anxiety tends to interpret the information around
them in ways that are either extra picking up on threatening
situations or misinterpreting things, so we just want to be
careful and for into – for when we think about racial
microaggressions, this may not be misinterpretations and often
are not misinterpretations.
So, we want to be really fair and
saying, in laying out the evidence for what’s, what’s
happening. So, we can be really clear and not be having
conversations where we’ve already arrived at a decision
and we’re just teaching you, that’s where, or dismissive in
some way. Anything you would add to that,
Jen? Jennifer Blossom: I think, to
the point that you’re making one of the things that we think
about when approaching a situation that kiddo or family
is describing as anxiety provoking, just kind of a
decision tree that we work through and initially you ask is
the fear realistic? So when I think about the question that
was asked, and the consequences of racism? The answer to that
would be yes. Right? The fear is realistic in that situation and
when that situation arises, then we work on figuring out if is this
something that the kiddo should know how to manage. If there are
specific things that we want them to know how to manage, then
we want to give them the skills to do that.
So, that’s kind of
our initial decision point there and I think that that’s where we
want to be thoughtful of experience of racism, there’s
the very real reason why that would be immediately threatening to
somebody. So that’s, that’s the lens through which we would approach
it. Yeah, totally agree. Totally
agree. All right. So, in terms of what teachers can do,
truthfully, we want teachers to work with students and families
as issues come up to encourage this idea of the approach
instead of avoidance.
I think Jen and I have both read a lot
of different, you know, IEP or 504 plans that have clauses in
it that end up accidentally reinforcing avoidance and then
our feedback is, is around how to turn this piece around so
that we’re actually moving toward the feared situation and
learning more adaptive responses, rather than
encouraging avoidance, just in order to reduce that experience
of anxiety and in many ways, we use a school-to-home note, which
I’ll show you in a second. I’m sure many of you have used
variations of these notes for different behavioral concerns
that have come up in classrooms and the application of this to
anxiety is not really so different but as you work with
youth with anxiety, I really think about how to be supportive
and what it actually means to be supportive to somebody with
anxiety and that means approaching situations with this
an important combination of both validation and confidence.
It’s
the “I know it’s hard and I know you can do it.” combination.
Oftentimes, we see people fall into traps where they’re just,
you know, holding on to one of those two pieces of that
equation. So either just validating like this is so hard
and kind of getting stuck in the admiration of the difficulty, or
holding on to the confidence piece of like, buck up, kid,
come on, you can do it, this is no big deal, and both of those
alone are problematic and in terms of moving anxiety
intervention forward, so we really need the combination of
both of those to build a supportive environment. Kendra Read: So just, you know,
as I mentioned, this is an example of a school to home
note, as we apply it to anxiety and I would imagine, you know, I
kind of took the framework from this directly from our ADHD
disruptive behaviors clinic, which shows you just how similar
the behavioral approaches can be.
So essentially, we just want
to set a behavioral goal with a family around anxiety, obviously
this example is for a younger child. If you look at the smiley
faces and all of that, we want to set like a really specific,
observable, time-limited, you know, smart goal around an
anxious anxiety or brave behavior. So for this child,
this example child, their goals are around, walking into class
independently, whispering to the teacher three times throughout
the day, and raising their hands during specials and then we want
to make sure that we’re giving them opportunities to reach
these goals, tracking their progress and then finding
having some way of coordinating that information back to parents
so that they can or other caregivers, so they can really
reward and reinforce their youth progress toward more brave
versus avoidant behaviors in the school setting.
Jennifer Blossom: Kenda, if you
could just go back to the last slide there is relevant to one
of the questions that came in asking about what age you can
use these principles with kids and, as noted, Kendra noted
here with the smiley faces, this is a school-to-home note that’s
really designed for, you know, kiddo as young as in
kindergarten, what we know is that you can employ these
strategies, you can use these approaches with kids as young as
three, you know, oftentimes, we’re then talking more to the
adults in the kid’s life. So, talking to the teachers, talking
to the parents or other caregivers, that these skills
and these strategies still work well, even with really young
kids and that oftentimes, if we can catch them that early, we’re
just setting them up for better success so that we can really
leverage the strengths of that of those brains that are wired
more towards anxiety and help them meet their goals.
Absolutely, thanks, Jen and I
would say that actually our anxiety programs go down to age
two at Seattle Children’s, and all the way up through age 18
and beyond. I mean, not at Children’s but these principles
are universal, regardless of age and there are just some
adaptations in terms of exactly how you would apply this for
different age groups. So as Jen mentioned, for kids, I would
say roughly seven and younger, I’d be working much more with
parents than with kids directly. That’s really different than
those than you know, it’s a different kind of story or
opportunity for those of you in school settings. So we can talk
more about that in the question and answer period if you would
like.
Kendra Read: Okay, as I
mentioned, in terms of supporting youth with anxiety in
school settings, we tend to see some common pitfalls, of tending
more toward accommodation versus approach in anxiety-provoking
situations in formalized 504/IEP plans and I -accommodation is
this good word, bad word. In a school setting, it tends to have
a really positive connotation. In the anxiety world, it has a
really negative connotation. So, accommodation means essentially,
you know, being complicit with a child’s anxiety and helping them
avoid anxiety-provoking situations. So when Jen and I
talk about accommodating anxiety, we’re thinking of, you
know, parents who will never ever go out on a date night
because their child doesn’t want to be alone or will never
eat at the same table as their kid because their child can’t
handle it, different things like that. So just want to note that
we use that word really differently across our different
settings but in general, it has it all goes back to that
approach versus avoidance difference. So, a lot of problematic
pitfalls that we run into are things like these
contra-indicated accommodations, like extra time, not calling on
a student or allowing, directly allowing avoidance of certain
specific activities.
Extra time is a really tricky one and I
know, we have a lot of conversations about this all the
time, it comes from a good place of wanting youth who may be
distracted by their anxiety to have more time to, you know,
manage that, when in reality, what tends to happen when we
give you extra time, when we give youth with anxiety extra
time is that they tend to spend that time worrying or engaging
in more anxious behaviors more avoidance, so it ends up not
being a helpful intervention in the end.
My internet connection is a
little unstable. So, apologies if I’m breaking up. As I mentioned, things like
relaxation strategies, strategies, and journaling are
not bad things to do, but they’re also not helpful. So we
would not want those to be considered the primary
interventions for anxiety in any setting and really, it also
comes down to really requiring this partnership from all
parties, from teachers, specialists, and caregivers, so that
there is a clear plan for what we’re working on and how we’re
going to be approaching this in a situation that is supportive
to the child, so involving that combination of confidence and
validation. The “I know it’s hard, and I know you can do it,
and here’s what we’re going to work on” and I think sometimes
we’ve, you know, heard from school-based personnel who feel
kind of reticent to approach exposures in their setting thing
like, “Well, I’m not a therapist, maybe I shouldn’t be
doing this.” but in reality, we all have ownership and agency in
this in this behavior change and this change in problem
problematic anxiety, even if you’re not a quote-unquote
therapist or psychologist, we need youth to practice exposures
in all settings in order for this to generalize to all
settings.
So, it’s really important that these things are
practiced in the school setting as well. Okay, Jen, come back on for our
Q&A. Jennifer Blossom: So, we have
been working with a lot of people internally at Seattle
Children’s, as Kendra mentioned, I was there. The working
remotely, as I’m sure many of you are just over a month ago,
as well as many, many people throughout the greater WWAMI
region and there’s been a few common questions that have come
up that we opted to highlight here and I’m also aware that
there have been a number of questions that may have been
coming in over the Q&A section. So, thank you so much for
sending those in, please feel free to continue sending those. So, my thought is that we’ll
just jump right into the question and answer questions
that are coming in. So I think one, one question in which I’m
seeing kind of a few iterations are going back to this idea of
the 504 plan and how we develop a 504 plan that acknowledges and
integrates the evidence-based recommendations for anxiety and
one of the ways that I think about that is really getting
concrete on some of the goals in the school setting and instead
of providing, providing kind of a blanket statement, like more
time to finish something is figuring out where the child
currently, what are they currently able to do, and where
do we want them to be? and then how do we find those steps to
get them towards that ultimate goal? So, how can we phrase
something that allows them to take steps towards participating
in the class? You know, being able to complete that assignment
when they’re asked to, in particular, think about a
a child who might have difficulty speaking in the classroom, one
of the questions that came in was relevant to whether we can
apply these principles to selective mutism and the answer
is certainly yes, Kendra and I do this a lot.
Kendra has a
specialty clinic that specifically works with families
and helping kids learn how to speak in settings that they feel
uncomfortable doing so. So, thinking about a 504 plan in
particular with a selective mutism kind of focus, if you
have a child who is completely nonverbal, who is not able to
speak out in the classroom, oftentimes what happens is we
find that teachers are jumping in or providing answers for
them. Other students might recognize again, well-meaning
compassionate people jumping in providing answers for them, what
we want to do is help, help encourage the child to start to
be able to answer the question themselves. So, a 504 plan might
say something like – initially might say something like respond
to nonverbal. So, being able to shake your head yes or no,
that’s still providing some kind of information in engaging in
some kind of communication.
If there’s the complete absence of
communication, then it might be being able to whisper an answer
to the teacher. So we can think about what is the
steps and how can we integrate them into the 504 plan? So that
we’re getting the student and supporting them to
be able to answer a question in the middle class when, when
other students’ peers are there. I would just add that, you know,
I know that 504 plans often we can’t change them as quickly as
we would like to change behavioral goals. So, sometimes
I encourage schools to phrase a 504 accommodation or an IEP
the goal, you know, honestly, IEP s with their, like the goal
framework kind of lends themselves a little bit more to
this idea but the idea that we’re going to gradually be
approaching and, you know, moving from totally not speaking
to respond, you know, 80% of the time to the teacher in at
least a voiced response. So, you know, if you put your hand on
your throat, you feel your hand vibrating, right, and we just
state in the plan that we’ll be identifying weekly goals.
The teacher will be providing, enough opportunities for the child
to reach their goal, and we’ll be providing support for the
child to try again and just kind of discuss what the
communication plan from school to home looks like because that
can – that looks different for every school that I’ve worked
with, depending on what’s feasible.
There’s no one exact
the right way to do it and that gives us a little bit more
flexibility to work on those successive shaping steps of
moving from, you know, just, you know, shaking our head, no, to
mouthing no, to then whispering, to then talking. So, the
exposures in school said that’s one example. Kendra Read: There are exposures
in school settings that can look so many different ways. It just
really depends on the different situation. So sometimes we are,
you know, as the adults in the situation, setting up some
social opportunities, for one child to talk to another,
sometimes it’s like, okay, just so you know, I’m going to call
on you during this part of the day or sometimes I – a lot of
kids have, are so anxious about making any mistake or they redo
and redo and redo their work or they, you know that, or there
work has to be perfectly neat.
So, then we have them turn in
work that they finished with their non-dominant hand or they
definitely made a mistake in there on purpose and they’re
going to turn it in and see what is so bad about this, what is
the worst thing that happens when I turn in a mistake? So
there are all sorts of different exposures that you do in a
school setting and it just so depends on the specific fears
that the child is endorsing. Okay, so let’s, there was a
the question at the top about PTSD and anxiety, and whether or not
they can co-occur or would not be concurrently diagnosed,
and absolutely PTSD and anxiety disorders can co-occur 100% they
can be diagnosed at the same time, we just want to be careful
that we’re not to double counting the same symptoms and
we want to be clear that not every anxiety disorder, you
know, anxiety disorders don’t come about because someone
definitely experienced a traumatic event.
Right. You
know, fear of spiders doesn’t mean they’ve definitely
experienced a horrible situation with spiders, for
example, or for selective mutism. This is one of the big
ones, where there’s this myth that they’ve experienced a
traumatic event and that’s why they’re not speaking. Not true,
but for PTSD, you know, that is like one of the only DSM
diagnoses where we know exactly that there was an event that
precipitated the onset of this disorder. So, it is common for
youth who have are just get like anxious. Pre-traumatic events say
they have social anxiety. A traumatic event happens they get
in a really bad car accident and they can’t get back in the car
anymore.
They have true PTSD related to the car accident, and
they have social anxiety. So these two things were not
double counting, but they are happening at the same time. Okay, Jen, I’ll let you pick
one. Jennifer Blossom: So, I’m seeing
a lot of questions and just getting some clarification
around skill building and why we are recommending against using
strategies like relaxation or journaling and so in particular,
just thinking about why and Kendra talks about relaxation in
terms of the message that sends or the threat of the physical
experience of anxiety and the general idea is that we want
kids to have that physical experience of anxiety and know
that does not automatically mean that the worst is going to
happen or that they’re not able to handle those feelings.
There are many situations we’re experiencing that physical
anxieties, really helpful.
In the beginning, Kendra was
talking about, you know, if you’re preparing, if you have a
test on Friday, and I have no anxiety about that, then I’m
probably outside playing with my dogs not sitting – in front of a
book trying to understand the material, right? In some ways,
anxiety is really helpful and adaptive. What can become
problematic is when anxiety is so high about the test that I
can’t even think about opening the book, because I’m so worried
that I’m not going to be able, to learn what I need to
learn. So, we really want to help, help kids and help
students figure out that I can notice that I’m experiencing
some of that anxiety but I can still do the things I need
to do. I feel anxious about the test but I’m still able to sit
down and focus on the material and study the way that I need
to.
When we tell them, “Oh you
notice that your heart is racing or you notice that your muscles
feel tense. Let’s take a moment and sit back and spend some
time breathing.”. What we’re doing is we’re sending the
the message that bad anxiety is really something to be worried
about or scary that they aren’t able to handle those feelings
and then what happens is when they walk into class to take
that test and they’re feeling those same feelings, they think
they can’t handle it.
So, we want them to do is practice
handling and practice tolerating. When I think about a
strategy, like journaling, one of the things that I think about
is that, you know, anxious brains again, they do a really
good job of thinking. They’re constantly thinking, they’re
constantly coming up with the what ifs, what if, what if,
that’s what gets in the way of sleep, that’s what gets in the
way of paying attention in class. So, if we ask somebody to
write down all of those thoughts, and those what-ifs,
we’re not necessarily giving them the skills or the
strategies to still be able to do what they need to do and in
In some cases, we may be letting those what-ifs allow for
avoidance because now they’re writing about those what ifs
instead of doing that thing, that’s hard and this is
something Kendra and I have just recently started talking about
kind of how can we rephrase and reframe thinking about exposure
and practice based on your fear as a coping skill.
I think
that’s one of the things that can get lost or is confusing is
that when we think about facing your fears that we’re ignoring
that, that is still is learning a coping skill because what I’m
learning is that when I feel anxious, I can still do what I
need to do. When I feel anxious, I can still pick up that book
and sit down and read the first paragraph when I feel anxious, I
can still open my computer to start writing that essay. That’s
coping skill and the way that you build that coping skills by
taking those smaller steps until you’re able to do that thing
that’s really hard. What would you add to that? Kendra Read: I would just want
to add about there’s this piece that we call expectancy
violations. We also want kids to have those learning experiences,
to see that the thing that I expect to happen, really doesn’t
always happen or even if it does, it’s not as bad as my
the brain is assuming it is.
This is the coping skill and I think a
lot of people get wrapped up in the toolbox, and I need to give
kids all these other things to do when they feel anxious but
the thing we need them to do is to practice staying in the
situation, and quote-unquote, riding the wave. So, I’m seeing
some other questions about like, what do we do in situations?
Like when a kid is anxious, what do I do? and really, when that
happens for me, like all day long, I just want to – I sit
with them and I say, okay, so you’re experiencing anxiety,
what’s happening in your body right now? How are you feeling
it? What’s your number? and so I want them to practice rating on
a scale from say, zero to 10, how anxious they feel. So,
that’s one way that they can build some mindfulness of saying
like, okay, I’m at like a seven right now and I’m noticing that
my stomach really hurts and that’s like, okay, so what are
you thinking at this moment? I’m thinking, I’m totally going to
fail this presentation, I’m going to bomb it, everybody’s
gonna laugh, etc, etc.
And say like, okay, well what is
happening in this situation is anybody laughing? Like, well, I
can’t hear that anybody’s laughing. So maybe they’re not.
Maybe they are in their own homes, but nobody’s mics are on
everybody’s automatically muted. So, if I don’t know, if they’re
laughing, how will it ever change my life? So, just some
thinking through some different situations like that to think
through that expectancy violation, violating what we
expect – the anxious anticipation of what’s going to
happen. Okay. Jennifer Blossom: I see, I think
we, I hope we answered some of the questions about the Final
Four Planner IEP is about how we can approach it. I see some
questions about like homeschooling and one on one
the school supports, and how do we help families understand this
and man, is it hard, you know, I just want to validate that like,
as much as we do this for a job, we don’t convince every family
that this is the important way to go and we really try to, to
bring them in and discuss how, you know, you know, one of the
other programs run at Children’s as a school avoidance program,
which is not running this fall because most schools are remote.
So, there’s no brick-and-mortar school to avoid for most of our
students, but what I tend to see is that the families that pull
out into homeschooling because of anxiety, those kids tend to
have really escalating very problematic anxiety, very
interfering anxiety that continues for years.
So it does
become a really big problem and so I just want to describe that
the trajectory that I see for them before they make that decision
and be very clear that homeschooling online homeschool,
That like we’re all pigeonholed into that right now
because of COVID or most of us are, so we’re not making that
decision because of anxiety but when we do make that decision
because anxiety is contraindicated. It is
problematic in terms of changing this cycle. So it’s very, very
much not recommended. ] Kendra Read: Jen, do you have a
the question you wanna? Jennifer Blossom: Yeah, I was
just searching through the Q&A and I see a lot of questions and
thinking about how we can adapt some of these recommendations
and approaches, particularly for older students.
So, thinking
about high school students, and thinking about it, there were some
comments about the student kind of report card can be more
challenging with a high school student and I think, you know,
in some ways, really just kind of working, working with the
student and figuring out kind of what’s going on for them at
school and at home. I think one of the things that we know that
comes up commonly when working with families is that oftentimes
parents are not necessarily as attuned to some of the things
that may be coming up at school for their kiddos, Kendra and I
have worked with families where, you know, after kind of years of
school difficulty and some anxious avoidance in high
school, that’s when the parent found out about kind of what was
going on.
So I think, really making sure to work as a team.
In some capacity, I think something that can happen
developmentally when working with younger kids that there’s a
tendency to exclude them completely as if they can’t
understand these principles. When, as Kendra says two and
three-year-olds, even if they’re not coming in for the treatment
the session, they get the idea that was brave, awesome job, right?
So we can still be working with them directly and integrating
these strategies with really young kids and in the same way
when you’re working with high school students, just as you
would reach out to parents for, other types of concerns, if
you were seeing chronic absenteeism or if there was a
lot of missed work but bringing parents in to support high
school students are a really helpful and a great opportunity
too as much alignment as we can get with practicing some of
these strategies both in and outside of school, I think can
be really helpful and effective and when we think about some of
the types of anxiety that we see, more commonly, social
anxiety is much more common in adolescence.
By very definition,
adolescence is a time period where we are more prone to peer
evaluation and judgments and that’s an opportunity that’s
ripe for the onset of social anxiety and fears, and really
coming up with creative ways to practice bringing on that
anxiety, like answering a question, just wrong,
purposefully making a mistake or having a long pause in the
middle of a presentation. Wearing a t-shirt to a zoom
meeting with a huge stain across the front, you know, thinking
about ways that you can help bring that on because one of the
things I know from working with lots and lots of teams with
social anxiety is that it’s really hard for them to be in
these situations and they really want those peer relationships
and connections. So, figuring out how we can work with their
own goals and use their own motivation to help them take
those steps, towards doing the things that they want
to do.
What would you add to that
Kendra? Kendra Read: You know, I’m not
sure that there’s a whole lot more I would add to that, Jen. You know, one of the things that
I’m noticing a lot of the questions are just like, yes,
but how do we do exposures? Yeah, how does what does it look
like? and so I just wanted to give a couple of more examples
for different kinds of areas that kids are anxious, about and how we can
do that in a school setting. So, we’ve talked a little bit about
how to set up, you know, brave talking exposures for selective
mutism. So, really, it’s setting a goal for Okay, so today we’re
going to whisper three times and so I’m going to give three
opportunities for you to whisper with me one on one, or I’m going
to get five opportunities and your goal is to do three out of
five. So, I’m going to come by your desk and say, what was the
answer to number four? and you’re going to tell me to
practice whispering to me the answer to number four.
A lot of
times as Jen was noting, we need some kid involvement in some
youth involvement in setting this goal. We need them to know
what the goal is, so that they can practice reaching it and
they can, we can give them some forced choice of like, okay, so
it sounds like from your parents that, you know, we’re going to
work on, you know, saying hi to a peer. So do you want to
practice that? This time of day or this time of day? Do you want
to do that with you know, you sit next to Johnny and Susie, do
you want to practice with Johnny or Susie first and I’ll be
listening. So just some, some different examples like that.
Practicing making mistakes, practicing, turning in imperfect
work.
I think I’ve said those already. Jen, do you have any other
specific exposure examples? I don’t want to overcomplicate
really what exposure is it really is simple. So like I’m
telling a kid, okay, let’s go do some trivia with some people
down the hall. Here’s a list of trivia questions I’m going to
give them I want you to get two of those wrong and then we just
go do it.
It’s really as simple as that. Jennifer Blossom: Yeah, I think
one of the things that come to mind, particularly when we think
about the context of COVID-19, is that everyone is managing a
lot of uncertainty right now and not being able to tolerate
uncertainty is a hallmark of anxiety, right? Anxious brains
want to plan they want to know they want to be able to
anticipate what’s going to come up, that’s where worry comes
from. Worry is a maladaptive coping strategy that if I think
about something enough, or if I think about all the possible
outcomes, then I’ll be prepared to handle them. So, when we
think about the current situation, in particular for
kids, maybe who didn’t have, didn’t have much anxiety before
wasn’t really getting in the way but right now with COVID and
everything and that there’s been a lot of back and forth, of not
knowing what to expect for school and as they get used to
the startup school still having, you know, trying to navigate
what’s going to be expected in terms of grades or things like
that is really opening up opportunities to practice
tolerating uncertainty.
So in going with the example that
Kendra had just had, of asking them to go answer questions that
they’re not going to know what the questions are in advance and
being prepared to answer questions that they’re
unexpected for, or having, you know, coming up with a plan
that’s not shared and advanced so that they can they can
tolerate being in a situation where they weren’t able to think
about and plan for really thinking about what are ways
that we can think about some of the uncertainty that is typical
of everyday life, COVID-19 is causing a lot of stress and a
a lot of realistic anxiety for people, particularly when we
think about the disproportionality of COVID risk
and consequences of COVID we know that there are going to be
significant mental health concerns for particularly
communities of color. So we want to think about, what are the
things happening right now? How can we, again, assess,
understand the full context for this kiddo? What are things that
are coming up? What are the objective risks that they might
be facing? and then what are ways that this anxiety might be
creeping in that it’s getting in the way of them being able to do
the things that they are able to do right now that they are able
to participate in staples that are going to keep them connected
to some of those, those social supports? and how can we
leverage some of the strengths that they might have currently,
certainly, Zoom meetings, Zoom parties, and Zoom classrooms are not
the ideal setting for many people, but there are ways that
we can still encourage that participation and get creative
with getting kids involved.
So I think, you know, the uncertainty
piece is one that I think comes up a lot. In particular, I think
again, we think of that as the – perhaps more commonly with older
kids, but certainly right now with COVID, because it’s just a
prime situation for us all to be thinking about it. So, think
of just different creative ways that you can help kids
experience situations that they’re not able to prepare for. I’m curious Kendra, have some
other ideas that you might have about thinking in a new school
context or particularly in the online school context? What are
ways to introduce uncertainty that would allow students to be
able to better tolerate that? Well, I think there are just a
lot of natural opportunities that come up that we can
capitalize on.
Sometimes I set up like more contrived
situations of like, okay, we’re going to do exposure and
you’re not going to know what it is or sometime this weekend,
your parents are going to change their plans. You don’t know when
you don’t know how you don’t know what it is. So different
things like that and their job is to tolerate that meaning to
keep their behavior within you know, appropriately behavioral
bounds, they can still experience anxiety and
frustration and so I would just note like, there are so many
natural opportunities coming up for us to tolerate uncertainty
every day with COVID and remote learning, and will we have
Internet connection? and will this work and, and all the other
things happening around us like, the wildfires, like there’s so
much uncertainty, and so much we don’t know and, and just sitting
in that place of like, what if we don’t know? What if there’s
no answer? and that feels really anxiety-provoking, but we just
need to sit in that place.
So I see a lot of questions like,
but what do I do during the exposure? What do I say to them?
and I really, especially when they’re starting to get really
anxious, and I really just say I want them to check in with them
just repeatedly to say like, hey, what number you at, what do
you – what are you doing? I know this is hard, but I know you can
do this. So just keep going back to that supportive statement of
I know this is how I think you can do it. I know you can stick
with this situation, and then point out all the little ways
that they are already doing it. Like, life is uncertain, and you
survived every moment of uncertainty up until today. So,
is there any evidence that you’re not going to survive the
uncertainty hereafter? No, we have no evidence that that’s
true. Might we have evidence that the opposite is true? So
the truth is, we all survive uncertainty every minute of the
day.
I don’t know what, I don’t know actually what’s going to
happen in the next hour of my life. I have some things that
might, you know, help me predict that but I don’t actually know.
So I think just pointing out all these little successes that they
may not be giving themselves credit for during the exposure
of like, you’re still here, you’re doing it like we’re just
going to ride this wave. You don’t have to do anything to
make this feeling come down. You are not responsible for that. It
just will. It is what it is. So we just need to stay in this
situation. So I really want everybody to release themselves
and have the responsibility to make themselves calm down, but it’s
nobody’s responsibility. It’s just what goes up will come down and
we’re just going to ride that wave. If you think about it
like you’re in the ocean and like the waves are coming and
you’re trying to push them back, like calm down waves, like
they’re just gonna knock you over, right? So instead if we
ride that wave, and we accepted remindful of it, and we’re like,
okay, like, how hard is this? What number is this? Okay, this
is a really big wave, oh, I’m going up really high.
Wow I’m
going really fast into the shore, right? We just want to
observe what’s happening. We’re more likely to experience
improvement and greater success in the situation than if we’re
like, must calm down, got to force this down. So, I really
want to let go of that sentence. Kendra Read: I’m jumping around
a lot, but I’m feeling the Jen, what did you want to
add? pressure of time. So, I just
want to note that there are some Jennifer Blossom: Yeah, so I
think just to kind of end and questions in there around
partnering with PCPs and other medical professionals. I want to
say that Jen, and I do have an ongoing connection with PAL or the
Physician Access Line here in the Northwest and we are creating and together we call laboratory Nat Young Bluth in into
connection for primary care for anxiety and OCD. So that is forthcoming
for those of you who are school nurses, I just want
your job to be is to help to connect some of
the somatic feelings that address some of the questions
that come up with how to help how we’re experiencing anxiety
and being a part of the goal setting with others around like may-
be their goal is to not check in at the nurse so much, which me
annoys that they’re avoiding the classroom, potentially
avoiding the thing that’s anxiety-provoking, and potentially
trying to just exit altogether.
That’s less so happens
in the times of COVID but just in terms of like what we typically
see. support when kids are in the
thick of the anxiety, while anxious brains do a really good
the job of being detail-oriented, those details tend towards the
threat. So, sitting with them and commenting on what they are
doing while they’re feeling anxious is really a way
an effective way to be supportive of students and help get them
engaged in exposure situations. So, if you notice that they are
feeling anxious, or they share with you that they’re feeling
anxious, commenting on what they’re able to do in that
moment, finding what it, finding, even if it’s a small
step, something that they are doing at that moment that is
helping them be effective in whatever the strategy is.
So,
thinking back about participating in a zoom class,
if a student went from not participating at all to using
the chat, jump on that, that’s the first step towards talking
in class and joining via video and joining the class. So, an
an effective strategy is really focused on what they’re doing
well because at that moment, it’s hard for them to see it and
that’s going to be a really rewarding opportunity for you
and for them to be able to continue taking these steps
towards facing their fears.
This has been really great. I’ve
so appreciated all the questions that you’ve raised. Kendra, and
I love doing these types of presentations and as she’s noted
multiple times, it’s a bit of a different situation not
seeing any faces, but we’ve really appreciated the
engagement and so looking forward to working with you and
meeting with you again, in just a few weeks, and with that, I’ll
turn it, Kelcey. Kelcey Schmitz: All right, thank
you. A huge thanks to Kendra and to Jen for their presentation
today. I know for me, personally and professionally, I couldn’t
take notes fast enough and for those of you who have
participated today, just a reminder that we will have the
recording up for you who like me will probably be watching this
and sharing it with other people who need to see this.
On the next slide, it’s just a
a reminder of how you can get in touch with us. We have many
opportunities for you to participate in live webinars, we
have many recorded School Mental Health webinars that you can
check out. We have a newsletter, that we send out monthly
newsletters and event blast to you. So, we just highly
encourage you to connect with us, especially if you’re in our
Northwest region but you’re also welcome outside of our region,
as well as reaching out to your local regional center to get
more support and then our last slide is to thank you and a
a reminder that part two, managing anxiety during COVID-19 will
happen on October 20.
So we hope that you will register for that.
I will say this, this session sold out so if you haven’t
registered already for session two, it might be a good
opportunity for you to take care of that now. We know we still
have lots of questions in the Q&A and we will carry those
forward to future events that we have with Kendra and Jen. So,
huge thanks to Kendra and Jen. Huge thanks to our Northwest
School Mental Health team that is been working behind the
scenes to help with the chat and the Q&A and just keep this
webinar running smoothly with that, we will officially
end the webinar but keep the room open for just a few
moments. So, you can take down those links and complete the
evaluation but at this time, I want to thank everyone and we
will end the webinar.
A high, prolonged cortisol level can mess with a lot of stuff. It’s even been seen to decrease the volume of your hippocampus, the area responsible
for learning and memory, and a reduced hippocampus
is more often seen in people with depression than those without. So all this is to say that the extra stress is probably not doing your brain or your body any favors. And humans are historically
bad at making decisions when they don’t know
what’s going to happen?
So, what can you do to
reduce the allostatic load? Reduce stress. Eating well, exercising, and maintaining a regular sleep schedule cannot be overlooked. Exercising alone can
reduce stress hormones, even with just a 20-minute walk. And a different way of
thinking could also help us: an idea called model-free learning. It’s trial and error. Instead of basing your risk assessment on similar examples from the past or envisioning future scenarios, you just take it one step at a time. This way, you reassess and
update your estimate of what’s happening and how to prepare. We’re dealing with a new virus, constantly changing policies, and likely a completely different schedule and maybe even environment. Our brain is on high alert at all times to identify potential threats.
This means that even if you’re spending most of your time laying around, your brain isn’t, so try not to beat yourself up for feeling tired or fuzzy, or unmotivated. You just don’t need anything
else to stress about. Now that you know all of this, how are you feeling? Alex: To be honest, I
do still feel the same. Fran: I think I’m feeling a
bit better after watching it. Victoria: It’s
my body is exhausted from feeling things and being under stress all day, all the time. Graham: Whenever I feel
that allostatic load starting to weigh down on me, you know, I can put a
name on it, a face on it, and it makes it a lot
easier to deal with it.
So we can see the overall
representation of the Cauchy stress tensor. So first is stresses acting on x
plane. Now which is the x plane, this is the x plane. So there are two
x planes, this is negative x and this is positive x. So what are the
stresses which are acting, we have sigma xx in the direction of x?
So, all of them are acting on x plane. Then we have sigma XY and sigma xz. Similarly,
on the other side of another plane which is a negative x plane we have sigma XY, sigma xz, and sigma xx.
It is identical but it is on the other side. Then we have stressed on y plane.
Now what is
meant by y plane, a plane with y direction as the normal. So you are talking about this and this.
So you have positive y and this is negative y. Similarly, in this, you have
sigma yy, sigma yy, which is the direction, in the direction
of y and you have sigma y x, sigma yz, similarly sigma y x and sigma yz. Then
we have stresses acting on the z plane, what are the stresses acting on the z plane, and
what is the z plane, this is the positive z plane and this is the negative z plane and
this stress is acting as sigma zz, sigma zx, sigma zy. Similarly, here also
you have sigma zz, sigma zx, and sigma zy. So these are the representation of the components
of Cauchy stress on a given control volume. So, all these stress components are acting at
a point. Now we need to keep in mind that I have shown a control volume in the figure, and
that is only for understanding how the stresses are oriented. Otherwise, it does not serve
any purpose. We need to still understand that whatever stress components are there in
the Cauchy stress tensor, it is acting at a point and the control volume, the cuboid is shown only
to indicate the plane on which it is acting. So that’s that notion we should not forget.
So it is stress acting at a point. Now having said that, we need to now define some
sort of sign convention of the Cauchy stress tensor.
So the given sign conventions are the traction
components on the positive plane. So now we have already marked what is a positive plane.
So the traction component on the positive plane acting in the positive direction means the
direction of x y z which is in the positive direction, so is positive. So you have a positive
plane and the traction component is acting in the positive direction, so it is positive.
Similarly, if you have a positive plane and the traction component is acting in
a negative direction, so it is negative. For the negative plane, if the plane is negative
and the traction component is acting in a negative direction, so it is positive.
And the final case
is negative plane traction component direction is a positive direction, it is negative. So this is
one sign convention, you can see that numerous sign conventions are available, and uh one may use them at his convenience, but if you follow one sign convention,
you need to follow it throughout. So this is one convenient way of uh defining sign
convention, there are assigned conventions that are available based on movement also, and sometimes
it may be difficult to understand. So this is very easy and very easy to define as well, one example
is given here.
So this is the positive x plane, and the stresses acting are sigma xx, sigma
XY and sigma xz. If you consider sigma xx, this is acting on a positive x plane.
And sigma xx is in acting in the positive x direction. So that is why it is positive,
similarly to sigma XY and sigma xz. Now consider the case of the negative x plane, if you consider sigma
XY, this is a negative plane, negative x plane whereas, this is acting in the positive y direction.
So negative plane positive y direction, so it is negative.
Similarly, all the stress
component signs can be assigned. So this is the sign convention of the Cauchy stress tensor. So what
is the summary that we have understood till now? There are three normal
components or normal stresses, sigma xx, sigma yy, and sigma oz. You can
see that in this figure, you have sigma x x, sigma yy, and sigma zz, these are acting in
the same direction as that normal. So there are three normal components or normal
stresses sigma xx, sigma yy, sigma zz or it is merely stated as sigma x, sigma
y, sigma z which is a common terminology, which we normally use in mechanics.
There are six shear components or shear stresses to be very specific all indices
were I not equal to j, here it is I equal to, here I not equal to j.
So these are shear
components of traction or shear stresses, it is written either in sigma form or in tau
form. Cauchy stress tensor a second-order tensor quantifies the internal force distribution in a
body at a given position and time corresponding to a given deformation.
Why time is important is because we are considering the condition
corresponding to a given deformation. And internal forces, which that gets developed
followed the basic laws of mechanics. Now one particular aspect of why stress
at a point that information is needed is to, define the equilibrium equation. So it is an
application of why you need to know stress at a point.
Now stress at a point is
very important to define the equilibrium equation as we have seen in the beginning, you have seen
that certain requirements need to be satisfied like the equilibrium condition,
the compatibility condition, and so on. Now for defining the equilibrium condition, we
need to specify the equilibrium equation. I will not go into the derivation of this equilibrium
equation it is very basic and is mostly seen by most of you. So by considering a given
control volume, the equilibrium equation can be represented as follows. And you can see that the
components of equilibrium equations are the stress tensor components, the only new term is gamma.
Where gamma is a self-weight of the gravity stress which acts in the z-direction or the vertical
direction and to be very specific stresses are in terms of total stresses in this particular
equation, it is invariably necessary to know stress at a point for defining
equilibrium condition.
Now based on equilibrium, we can say that tau yx is equal to tau XY, tau
yz is equal to zy and tau zx is equal to tau xz. Therefore, the stress tensor is represented
by six independent stress components, there are nine components in the Cauchy
stress tensor just because of this condition, we have six independent stress components, and
they are three normal stresses, sigma x, sigma y, sigma z, and three shear stresses tau XY, tau
yz and tau Zx, where tau XY is equal to tau yx. So this is what it is. So that is how it boils
down to six independent stress components. So the final summary of what
we learned in this particular lecture is Cauchy stress, sigma is a second-order
tensor. The element of stress tensor represents components of traction acting on three orthogonal
planes according to a given Cartesian coordinate. Sigma I j means j component of traction vector
acting on the ith plane. Stress tensor sigma has three normal stress components and six shear
stress components.
But based on equilibrium, there are six independent stresses
three normal and three shear stresses. All the stress components are acting at a
point that is very relevant and which is very important. The components
of sigma depend on the coordinate axis, please note here as such sigma
is not dependent on the coordinate axis, but the components of sigma, I mean to say
sigma x, sigma xy those are the components or the traction vector components, they
are dependent on the coordinate axis. So there is a distinction that needs to be
very clear, one should not get confused with sigma as a whole and the components of sigma.
Sigma as a whole is not dependent on any axis, but the components of sigma keep changing, but
the overall sigma representation of internal force remains the same depending on the reference axis,
and the component’s magnitude value keeps changing. Stress tensor sigma at any point in the body
defines the internal force distribution of a body. So this is all about this particular
lecture, which we will see in the next lecture.
It is an organ
that actively releases hormones and immune system chemicals
called cytokines that can increase your risk
of developing chronic diseases, such as heart disease
and insulin resistance. Meanwhile, stress hormones
affect immune cells in a variety of ways. Initially, they help prepare
to fight invaders and heal after injury, but chronic stress can dampen function
of some immune cells, make you more susceptible to infections,
and slow the rate you heal.
Want to live a long life? You may have to curb your chronic stress. That’s because it has even been
associated with shortened telomeres, the shoelace tip ends of chromosomes
that measure a cell’s age. Telomeres cap chromosomes to allow DNA to get copied
every time a cell divides without damaging
the cell’s genetic code, and they shorten with each cell division. When telomeres become too short,
a cell can no longer divide and it dies. As if all that weren’t enough, chronic stress has even more ways
it can sabotage your health, including acne, hair loss, sexual dysfunction, headaches, muscle tension, difficulty concentrating, fatigue, and irritability. So, what does all this mean for you? Your life will always be filled
with stressful situations. But what matters to your brain
and entire body is how you respond to that stress. If you can view those situations
as challenges you can control and master, rather than as insurmountable threats, you will perform better in the short run
and stay healthy in the long run.
For example, the smell of a campfire could evoke the memory of being trapped
in a burning house. For someone with PTSD, that memory activates the same
neurochemical cascade as the original event. That then stirs up the same feelings
of panic and helplessness as if they’re experiencing
the trauma all over again. Trying to avoid these triggers,
which are sometimes unpredictable, can lead to isolation. That can leave people feeling invalidated, ignored, or misunderstood like a pause button has been
pushed on their lives while the rest of the world
continues around them. But, there are options.
If you think you might
be suffering from PTSD, the first step is an evaluation
with a mental health professional who can direct you toward
the many resources available. Psychotherapy can
be very effective for PTSD, helping patients better
understand their triggers. And certain medications
can make symptoms more manageable, as can self-care practices,
like mindfulness and regular exercise. What if you notice signs of PTSD
in a friend or family member? Social support, acceptance, and
empathy are key to helping and recovery. Let them know you believe their
account of what they’re experiencing, and that you don’t blame them
for their reactions. If they’re open to it, encourage them to seek evaluation
and treatment. PTSD has been called “the hidden wound” because it comes
without outward physical signs. But even if it’s an invisible disorder,
it doesn’t have to be a silent one.
