Unlimited CEUs for $59 are available at AllCEUs.com/Trauma-CEU this episode was pre-recorded
as part of a live continuing education webinar. CEUs are
still available at AllCEUs.com/Trauma-CEU welcome to today’s presentation on the
neurobiological impact of psychological trauma on the HPA axis we’re going to define and explain
the HPA axis which we’ve talked about before is a response system so it’s not
anything to get to you know overly concerned about that it’s going to be super dry well identify the
impact of trauma on this axis and on basically your whole nervous system in your brain identify
the impact of chronic stress and cumulative trauma on the HPA axis because a lot of times when
we talk about PTSD we think only about some particular acute event and that’s not necessarily
true there are a lot of people with PTSD who have basically what I call cumulative trauma and they
were exposed to extensive child neglect they were in domestically violent relationships they were
in a situation where they were exposed to trauma over and above what a normal person would think lawfully think of law enforcement military personnel think first responders I mean
they see stuff that no human should have to see and they see it not only once but you know once
a week or once a month depending on kind of where you are so it’s important to understand well
one thing may not be so traumatic to create post-traumatic stress we’re going to look at some
of the reasons that PTSD symptoms may develop as a cumulative sort of thing which I found this
to be interesting anyway we’ll identify symptoms of dysfunction and we’ll talk about some
interventions that are useful for this population now my guess is none of you are prescribing
physicians so when we’re going through this you’re going to be going yeah that’s all well and good
what’s the exact point of thinking about exactly what this information is telling
me on each slide show used to be the hat to help my clients who have been annoyed by trauma and
have not yet developed any sort of PTSD symptoms or who have PTSD symptoms and how can I use this
information to better tailor my treatment plan to help them become more effective in managing their
symptoms this is kind of a unique presentation because it was based on only one article this
was a meta-analysis so it’s a long article and it’s a really good article that I would
strongly suggest looking at it in your resources section in the class it lays out the many changes
and/or conditions that are seamed in the brain and nervous system of people with PTSD so they really
looked at a lot of research longitudinally to see what we know and what we don’t know as clinicians
awareness that these changes can help us educate patients about their symptoms why do you feel this
way and find ways of adapting to improve quality of life so neurobiological abnormalities in PTSD
overlap with features found in traumatic brain injury so that started making a lot of researchers
go hmm you know traumatic brain injury there is something or again of course hurting part of
the brain so why are the symptoms similar in PTSD you’re going to find out pretty
soon is that PTSD does cause damage actual physical damage in the brain the response
of an individual to trauma depends not only on the stressor characteristics but also on factors
specific to the individual so somebody can see a trauma and not be as traumatized if you will as
someone else and part of these factors and there was a study done by Pi Newson Nader back
I believe the early 80s looked at triage factors for PTSD and some of the factors that
they found why certain traumas may be more traumatic than certain people versus others have to do
with this particular trauma, you’re experiencing it close to one of your safe zones where you
live where you work somewhere where you’re not where you’re supposed to be feel safe and if
so then it’s probably going to be perceived as more traumatic now again think about the survival
capacity or the survival function of this behavior when your brain says this is supposed to be a safe
zone and it’s not so I need to respond in kind you’re trying to protect yourself make sense the
similarity to the victim if it could happen to her if it could happen to him they’re like me it could
happen to me that makes me feel scared because we like to categorize the world in terms of using them
bad things happen to those people not to us people but if you’re looking at a victim who’s liked you
and you say well I am and us people then you’re going to have more difficulty separating it and
feeling safe and going well that couldn’t happen to me and the degree of helplessness you know if
you saw something and you were just like there was nothing I could do there’s a greater sense of
helplessness and horror then if you didn’t have that necessarily that same experience so those
are a couple of things as far as the prestress or perception that we want to consider when we’re
talking to our patients even if you’re not a therapist that works with the trauma specifically
some people refer out for that some people are working with an EMDR therapist and you know cool
but as important to understand and if you happen to go down this road with your clients help them
understand why they perceived that particular stressor so intensely versus some other stressor
that they think may have good English there oh well sorry they think should have stretched
them out more so their perception of the stressor prior traumatic experiences and we’re going to
learn that prior traumas do cause changes in the brain to prepare you basically
Therese bond more quickly when there’s a threat so prior traumatic experiences can send you from
zero to 100 a lot faster which means it’s going to be or could be more traumatic the amount of
stress in the preceding months if you’re already worn down and your body has already said I can’t
fight anymore it’s not doing any good then when it encounters PTSD and when it encounters a
trauma the body might be going I just can’t take another thing please just I can’t do it which
is why we see in people with PTSD chronic stress burnout and chronic fatigue this inability to
tolerate stress because the body’s just already waived them that white flag going I can’t do it
current mental health or addiction issues again that’s your body’s way of saying something in
the neurotransmitter something in the system is a little bit wonky and that means I’m not
going to be able to respond a hundred percent healthy and functionally to whatever’s going
on and the availability of social support now a lot of the research especially with emergency
service personnel points to the availability of social support within 24 hours of the trauma
so when there’s an officer-involved shooting when there’s something that they encounter on
the duty that’s trauma the ability to have social support within that first 24 hours preferably first
two-hour period to at least touch base with a social positive social support is vital to
helping somebody process the memories instead of just kind of them disappearing into never-never
land and getting solidified in an unhelpful way for the vast majority of the population though
psychological trauma is limited to an acute transient disturbance you see something that’s
traumatic you’re like oh my gosh Wow it is devastating and yeah is going to affect you for
a little while but in a week or two you’re kind of feeling like you got your land legs again so
there’s this subpopulation of the population there’s a small group that ends up developing
PTSD the signs and symptoms of PTSD reflect a persistent adaptation of the neurobiological
symptoms to witnessed trauma and I crossed out abnormal in the article it says abnormal and
I look at it as a perfectly normal adaptation because the body is either going with the reserves
I have right now I can’t deal or you know whatever it’s doing it’s trying to protect itself now it
may not be helpful but from a survival perspective it generally makes sense so I try
when I’m working with clients to help them see the functional nature of their symptoms
given the knowledge they had or the state they were in at the time so now to the HPA axis the
The hypothalamic-pituitary-adrenal axis aka your threat response system controls reactions
to stress and regulates many body processes including digestion the immune system mood and
emotions sexuality energy storage and expenditure so let’s think about this real quick when you’re
under stress, your body feels threatened I needs to survive so it sends out excitatory
neurotransmitters that get you wired up which kind of makes your digestion speed up
it can cause some cramping in the abdominal area your immune system is not really important
right now threat we’re not worried about the flu mood and emotions you tend to
be hyper-vigilant and more easily startled threat means fight or flee which means anger or anxiety
so you’ve got some stress emotions and I don’t want to say dysfunctional because they’re very
functional your body perceives a threat and it’s saying you need to do something sexually well if
there’s a threat this is no time to procreate so your body says let’s turn off those sex hormones
right now, because we need to use us for fighting and fleeing not procreating which is all well
and good but when we have reduced sex hormones it also reduces our serotonin availability which
serotonin is one of those calming chemicals which help us calm down the excitatory neurons
so without them, you stay revved up which brings us to energy storage and expenditure you’re
revved up you’re on high alert you’re staying up here and your body says you know what if
I’m going to survive this fight or flight I need fuel which means you need to eat preferably
high-fat high-sugar foods that give us instant energy and sustained energy we want calorie defense
stuff now thinking about it from that perspective you can see how when you’re under chronic stress
or a big stressor you know some of your symptoms make sense why do you want to go eat chocolate
or do whatever you do that’s my go-to pizza and chocolate when I’m stressed is generally what I
crave not what I need but what I crave so we want to help people understand that there’s a reason
it makes sense now we just have to figure out how to deal with it differently the ultimate
result of HPA axis activation is to increase levels of cortisol in the blood during times of
stress now cortisol is the hormone that goes out and sets off kind of this whole well there are
a couple before it but it sets off this whole event cortisol is your stress hormone cortisol
is the one who says no sex hormones right now you know and it monkeys with all your different
hormones to make sure and your energy storage to make sure that you’re ready for this fight or
flee its main role is to release glucose into the bloodstream in order to facilitate the fight
or flight now glucose is sugar is raising your blood sugar so you’ve got energy now we’re going
to talk regularly about glucocorticoids which are glucose hormones that make your body release
glucose which is mainly cortisol and that term is going to become important later I’m just
kind of throwing it out there right now cortisol also suppresses and modulates the immune system
digestive system and reproductive system so again cortisol is saying we’ve got this energy we’ve got
this threat let me figure out how to sort of dole out our resources right now for survival in the
now it’s cortisol is very present focused it’s not looking at you know the long-term and
going well this will pass cortisol is very right now HPA axis dysfunction the body reduces HPA axis
activation when it appears further fight-or-flight may not be beneficial and they call this hypo
cortisol ism so basically a threat response system is you know warning the alarm in
my dorm when I was in college used to have these really annoying blinking lights I because why I do
this all the time sorry the hypercritical ism is your body’s response to going if I keep fighting I
am just throwing good energy after bad there is no sense in surrendering so it turns down the system
and it stops producing as much cortisol that way it has cortisol your stress hormone for when there
is a bigger more threatening threat well what does that mean well we need cortisol is what
helps us get up in the morning our cortisol goes up and down throughout the day which helps us
have the energy to get up go to work do those sorts of things it’s a normal hormone when it’s
in the right balance hypo cortical cortisol ISM seen in stress-related disorders such as chronic
fatigue syndrome burnout and PTSD is actually a protective mechanism designed to conserve energy
during threats that are beyond the organism with us ability to cope so dysfunction in the axis
causes abnormal immune system activation so you have increased inflammation and allergic
reactions cortisol is also related to cortisone your body does not release its
natural antihistamines when you are pardon me under stress which is why your allergies seem to
bother you more which when your allergies bother you more you’re probably not sleeping as well at
night and we know that not sleeping as well at night keeps your HPA axis activated so you’re
fighting this battle you’re trying to squeeze blood out of a turnip basically because your body
said we’re not releasing any more cortisol I don’t care what you say but everything else you’re not
sleeping as well you’re still kind of revved up you’re fatigued and your body is going but there’s
a threat and back in your brain they’re going yep but it’s not a big enough threat yet so you can
see where this cascade you’re fighting inside your own body and all your systems are kind of arguing
irritable bowel syndrome such as constipation and diarrhea because cortisol speeds things up and if
you don’t have enough cortisol you know what might happen reduce tolerance to physical and mental
stresses including pain remember I said that sex hormones go down which means that the availability of
serotonin goes down we know that serotonin is not only involved somehow in mood it’s involved
with some level of anxiety reduction but we also know it’s involved in pain perception
so when serotonin goes down we perceive pain more acutely and altered levels of sex hormones
so fatigue and you’re like where did that come from well the HPA axis is activated see how
many times I can say that without tripping on my tongue when it’s activated it sends out these you
know excitatory neurotransmitters when you’re excited for too long you get fatigued
well interesting little caveat or thing here fatigue is actually an emotion generated in the
brain you know we’ve learned to label it which prevents damage to the body when the brain perceives
that further exertion could be harmful sounds similar to hypo cortisol ISM it is so what do
we know from athletes we know that fatigue and sports is largely independent of the state of
the muscles themselves so fatigued you know your muscles usually only work up to about 60% of
their ability to work and then fatigue starts to set in so there was still a big margin that you
could work before your muscles finally gave out and said hold no more I’ve got jelly legs but
your muscles quit you start feeling tired you start feeling exhausted so this is a protective
mechanism the body’s gone we need to conserve a little bit of energy because you have to get home
and shower and you know prepare to run in case the tiger chases you but what factors is your body
paying attention to but tells it OK whoa we need to stop so we’ve got enough reserve in the event
of a problem core temperature, you’re working out your core temperature goes up at a certain point
it goes that’s high enough your glycogen your blood sugar levels your oxygen levels in the brain
how thirsty you are whether you’re sleep-deprived, to begin with, it’s going to mean that you fatigue
a lot easier and the level of muscle soreness and fatigue going into that exercise session the
brain kind of takes all these factors into effect and goes okay I can unless you work out
this much and then I’m going to shut you down I’m wrong it’s off what they have found though
is we can override this so when clients come into our office, they’re fatigued they are they’re off
they’re just like I’m exhausted I’m agitated I’m irritable I’m not sleeping well I just uh okay so
with athletes, we know that psychological factors can be used to reduce fatigue such as their
emotional state if they go in in a positive emotional state or a hyped up energized emotional
state if they’re listening to really energizing music it can help them push past that fatigue
point a little bit if they know the endpoint maybe they know they’re doing three sets of ten
reps they’re going to push through faster or more effectively than if they’re working with the coach
and they have no idea how many sets they’ve got or how many reps they’ve got to do they’re just like
are you going to make a stop to other competitors that service motivation they’re looking around they’re
seeing other people doing it they’re going okay I got this and in the case of athletes visual
feedback you know they’re seeing growth in their muscles they’re seeing positive changes so they
can push through that fatigue a little bit more they’re like okay this is worth it so fatigue
is one sign that the body is getting ready to down-regulate that HPA axis and go conservation
in practice and counseling practice how can we help reduce mental fatigue and help clients
restore their age PA access functioning and one of the things I would challenge you to think
about is how can we increase their self-efficacy and their high ductless if you will in their
the emotional state that a can-do attitude increases their hardiness and resilience you know we talk
about those, a lot man make sure they know their endpoint where are they going what does their
what do their symptoms look like what is it going to look like in three weeks in three months
and what can we reasonably think will change you know let’s give them some tangible goals that
they can look at other competitors or motivational group therapy can be very helpful in dealing
with some of this stuff obviously, you’re not going to do a lot of trauma work in the group most of the
time but having other people around knowing that there are other people who are dealing with
PTSD and having support groups can be really helpful because they can cheer each other on and
go come on John you got this you just need to push I know this is a really tough week for you and
that can help people push through that fatigue and feedback now in the case of psychological
issues we’re not talking about visual feedback but we’re talking about looking at that treatment
plan or looking at their symptoms and being able to say you know what I have made progress I’m not
having nightmares as much as I actually slept through the night last night who knew and finding those
things that they can latch on to and go things are getting better you know they’re not going to get
exponentially better overnight likely but they are getting better and I can see this incremental
progress and in doing that we can help people get a sense increase that those dopamine levels
increase that learning and go okay I can do this we want to make sure that we are considering
their fatigue level though and not putting too much on them at once let’s look at really
small steps and then solidifying those steps not taking one step after another but taking one step
and then taking a breather for some of our clients helping them identify how they’re feeling and
be aware of their own fatigue level low cortisol has been found to relate to more severe PTSD
hyperarousal symptoms and you’re like yeah it took me quite a while to wrap my head around this
whole concept but it makes sense now so when you have low cortisol your body is conserving all
its energy can in case it needs to respond to an extreme threat the sensitized negative
feedback loop in veterans diagnosed with PTSD have they’ve shown that they’ve got greater ludic
corticoid responsiveness now remember I talked about cortisol being a glue to co-corticoids and
there’s just no nice way to talk about this without using really obnoxiously clinical
terms anyhow which means that the body is holding on and it’s going you’re not going to have cortisol
to just get irritable or happy or excited about just anything but if there’s a threat I’ll let you
have it unfortunately in patients with cortisol ISM when there’s a threat they have an exaggerated
response thank hyper-vigilance and I call it the flatter the Furious so their mood is either kind
of flat and they’re not really responsive too much but when there is something that startles them or
their body perceives as a threat all of a sudden their body dumps cortisol and dumps glucose into
the system which floods the system and if you’ve ever flooded your engine you know what happens
doesn’t respond quite as well but there are even more problems with this so evidence says that the
role of trauma experienced in sensitizing the HPA axis regulation is independent of PTSD development
okay so what does that mean that means even if somebody doesn’t develop PTSD clinical diagnosis
if they’ve had trauma HPA access is going to sensitize them a little bit and hold them back a little bit
more cortisol and be a little bit more reactive when there is trauma which means successive
traumas could produce success successively significant reactions in those with prior trauma
maybe more at risk of PTSD for later traumas so again as a clinician what does this mean for
me this means that if I’m working with a client who comes from a troubled childhood there were
adverse childhood events or you know whatever you want to label it they had chronic stress they
had trauma in their childhood even in the prenatal period they found I wanted to educate them about the
the fact that they are at a greater risk of developing PTSD if they’re exposed to more trauma so they
can learn how to keep their stress levels under control because it’s more important for
them according to this research because of some persistent brain changes that we’re going to see
core endocrine factors of PTSD include abnormal regulation of cortisol and thyroid hormones okay
so we’ve already talked about cortisol our stress hormone and you’re probably familiar with thyroid
hormones being sort of your metabolism hormone but what happens when cortisol goes down in the body
starting to rein in the energy thyroid hormones also go down hypo cortisol ism and PTSD occurs
due to increased negative feedback sensitivity of the HPA axis okay studies suggest that low
cortisol levels at the time of exposure to trauma may predict the development of PTSD so if their
cortisol levels were already low they were already suffering if you will from hypercortisolism and
remember we’ve seen hypercortisolism in burnout and you know regular old burnout chronic fatigue
syndrome as well as PTSD so we’re not just talking about veterans here if the cortisol levels are
already abnormally low and the body’s already started conserving cortisol when they’re
exposed to a trauma we can with more certainty predict which people are going to develop PTSD
symptoms back to those gluteal corticoids they interfere with the retrieval of traumatic memories
an effect that may independently prevent or reduce symptoms of PTSD so when cortisol is in
the system and it’s causing all the blood sugar to develop we’re not forming lots of
memories right now we’re just surviving which they hypothesize could prevent or reduce the symptoms
if those memories aren’t consolidated and they go away, or it could contribute to difficulty
in treating PTSD why well let’s think about it if people who’ve been exposed to trauma you
know hypercortisolism they respond to threats by increasing the amount of cortisol and political
corticoids exponentially have an exaggerated response than when they’re in our off and
we’re talking to them about their trauma, and they start to get upset they start to get excited there
the body’s going to start dumping all these gluten coke or turquoise and guess what it’s going to make it
more difficult for them to retrieve those memories potentially so it’s kind of an interesting thing
to look at because a lot of clients that I worked with PTSD have been like I can’t
remember why can I not remember and my very general response because they don’t want to know
about all this stuff generally is it’s your brain’s way of protecting you it’s your brain’s way of
saying there’s a threat right now and you need to protect yourself from the threat we don’t need
to be worrying about all those memories back there so we do some you know relaxation activities and
those sorts of things to help them you know get back down to baseline so we’re not continuing to
fight against those gluten Co corticoids and thus cortisol because when you fight with that what
happens the client generally gets progressively frustrated progressively upset and progressively
unable to think clearly and access those memories neurochemical factors corner or chemical
factors of PTSD include abnormal regulation of catecholamines serotonin amino acid peptide and
opioid neurotransmitters each of which is found in brain circuits that regulate and integrate the
stress and fear response now again if you’re thinking I’m never going to remember this for the
quiz don’t get too stressed out about it because I want you to take home the overarching concepts
I’m not going to ask you really nitpicky questions about stuff that you have absolutely no control
over or at least that’s what I tried to do that being said I want I think it’s important that you
know that all of these neurochemicals including opioids are involved in the regulation and
integration of stress and fear responses it’s not just serotonin or two dopamine the catecholamine
family including dopamine and norepinephrine are derived from the amino acid tyrosine now it’s
not really all that important but an interesting little aside is that norepinephrine is made from
the breakdown of dopamine so your focus and get up and go chemical is made from your pleasure
chemical interesting little concept there when a stressor is perceived the HPA axis releases
corticotropin-releasing hormone which interacts with norepinephrine to increase fear conditioning
and encoding of emotional memories enhance arousal and vigilant vigilance and increase endocrine
and autonomic responses to stress so when the threat response system is turned on it releases
cortisol which interacts with norepinephrine the stress hormone and they get up and go hormone
say there’s some really bad mojo brewing here which increases fear conditioning because the
heart rates go in and everything and the response is stress there’s an abundance of evidence
that norepinephrine accounts for certain classic aspects of PTSD including hyperarousal heightened
startle and increased encoding of fear memories so what about serotonin you know that’s supposed to
be one of our calming chemicals it where did it go poor serotonin transmission and PTSD
maybe may cause impulsivity hostility aggression depression and suicidality remember you’ve got
the downregulation of the sex hormones so less availability of serotonin and there are other
things that cause the serotonin to not be as available but they found that serotonin binding
to 5h t1a receptors and this is just a little soapbox I’m going to go on don’t differ between
patients with PTSD and controls so what does that tell us that’s the only way we can really
To figure out what’s going on in the brain in a live subject look at PET scans what we have figured
out or they’ve hypothesized is the fact that the serotonin may not transmit as effectively as it may
be a really weak connection it’s connecting but it’s you know it’s kind of like having a rabbit
ears you got to twist it to get the signal to come in correctly all right this is another one
just a concept I want you to think about all they’re looking at in the research is the 5-hit
1a receptor there are a ton of 5-ht serotonin 5-ht receptors and each one of these receptors is
involved in some aspect of addiction anxiety mood sexual behavior mood sleep so when we’re talking
about why SSRIs don’t work well SSRIs only bind to certain receptors and if we’re not picking
the right receptor if it is the serotonin at all then we’re probably barking up the wrong tree
I educate my patients about this if they decide they need to go on antidepressants just so they
don’t get frustrated as easily I mean it’s still frustrating but so they don’t feel hopeless if
the first medication they start taking doesn’t seem to work or makes it worse we talked about why
that might be because there are so many different receptors for each one of the neurotransmitters
there is a really cool table if you’re into this stuff it’s actually on Wikipedia and it talks
also about not only what these receptors do but also what chemicals and medicines act on
these receptors and how Food for Thought GABA has profound anxiolytic effects in part by
inhibiting the cortisol norepinephrine circuits so it turns down the excitatory circuits
patients with PTSD exhibit decreased peripheral benzodiazepine binding sites well we know that
when the body secretes a neurotransmitter goes to the other end and it binds like a lock-and-key
if you will or it knocks on the door and the door gets opened and it goes through however you want
to think about it basically what they found is in patients with PTSD the Kem GABA goes through
and the GABA levels are okay but then it knocks on the door to get let in or it tries to put its
key in the lock and there’s something wrong at the binding sites or the binding sites you know
somebody’s super glued them shut and they’re just not there which is why patients with PTSD tend
to have a harder time de-escalating when their anxiety and stuff gets up because the GABA is
there but it’s got no doors to go through no locks to bind with however you want to whatever
metaphor you want to use this may indicate the usefulness of emotion regulation and distress
tolerance skills due to the potential emotional dysregulation of these clients so remember we
talked about them having a more exaggerated get-up-and-go response to a perceived threat and
they also have a harder time calming down which is basically one of your primary tenants of emotional
dysregulation so one thing clinicians can do is help patients learn that okay their body
responds differently to stress than other people at least for right now so it’s important for
them to understand what emotional dysregulation is emotional regulation strategies as well as
distress tolerance skills to help them until they can calm down to baseline because it sometimes
takes them longer than other people as clinicians we also can help reduce excitotoxin in order to
reduce stress improve stress tolerance and enable the acquisition of new skills when the brain gets
really going when the cortisol is out there and the glucocorticoids are in there it’s actually
toxic and starts causing neurons to disappear which we’re going to talk about in a second it’s
kind of scary NMDA receptors have been implicated in synaptic plasticity.Which means the brain’s
ability to adjust and adapt as well as learning and memory so these are good receptors I like
them glutamate binds with these receptors and high levels of glutamate are secreted during high
levels of stress glutamate remember is what GABA is made from but high levels of glutamate
it’s an excitatory neural net in the brain and overexposure of neurons to this glutamate can be
excited toxic and may contribute to the loss of neurons in the hippocampus of patients with PTSD
so we’re actually seeing brain volume decrease as a result of exposure to certain chemicals elevated
gluten core glucocorticoid and yeah glucocorticoids increases the sensitivity of these receptors so
you’ve got a bunch of glutamate being dumped and you’ve got a bunch of glucocorticoid you’ve got
cortisol in there making these receptors more sensitive so it’s got they’re more sensitive and
they’ve got more coming in which makes it a whole lot easier to become toxic and start causing
neuronal degradation what does that mean why do we care it may take clients with PTSD more time to
master new skills because of emotional reactivity but also because some of their synaptic plasticity
may be damaged so it may take them a little bit longer to actually acquire and integrate these
new skills it’s not saying they’re stupid they can remember it just fine however when they’re
an emotionally charged state and helping their brain learn that okay this isn’t a threat that’s one
of those sort of subconscious things that has to happen that can take longer if the brain becomes
excited toxic during stress inhibited learning and memory then it becomes excited toxic during
stress which inhibits learning and memory so it’s under stress things are excited toxic neurons
are starting to disappear so I’m wondering and I’m just hypothesizing here I don’t know the
answers obviously or I wouldn’t be practicing it but what happens during the exposure therapies
because that’s exactly what we’re doing is we are flooding the brain with all of these chemicals
and creating basically an excitotoxin now they found some evidence that exposure therapies can
be helpful according to the DOJ website but or not the DOJ I can’t even think of it right
now the VA website but you know I’m wondering long-term what the impact is endogenous opioids
natural painkillers act upon the same receptors activated by exogenous opioids like morphine and
heroin exerts an inhibitory influence on the HPA axis well we know that people take opiates
and it has depressant effects on them it slows them down and calms them down alterations in our
natural opioids may be involved in certain PTSD symptoms such as numbing stress-induced analgesia
and dissociation again think of any clients you’ve had who have been abused or even taken and not like
the side effects of opiates are what opiates do to some people make them feel more relaxed stress
induced and analgesia they don’t have as much physical pain sometimes they just it’s there
I don’t care pill another interesting factor is now truck zone which is used to oppose opiate
appears to be effective in treating symptoms of dissociation flashbacks in traumatized persons so
basically, they’re saying if we undo the endogenous opioids we can treat these symptoms it highlights
the risk of opiate abuse for persons with PTSD though because if endogenous opioids produce
some of these numbing symptoms and dissociative symptoms so they can get away from the pain and
the flashbacks then if they add to that you know oral opioids it could prove to be a very tempting
cocktail we do want to as clinicians figure out how we can assist them with their physical and
emotional distress tolerance so they don’t feel the need to numb and escape and you know I
can’t imagine what some people have seen have gone through and I’m not trying to take that away
from them, I’m trying to help them figure out how they can stay present and learn to integrate it
changes question marks in brain structure and one of the questions that’s come up in the research is
because there aren’t any longitudinal studies that looked at it was the hippocampal volume as low to
begin with which created a predisposition for PTSD or did PTSD create the smaller hippocampal volume
interesting hippocampus is implicated in the control of stress responses memory and contextual
aspects of fear conditioning so it helps you to find these triggers in the environment that
help you become aware with your senses about when there might be a trauma prolonged exposure
to stress and high levels of glucocorticoids damage the hippocampus we’ve talked about that
hippocampal volume reduction in PTSD may reflect the accumulated toxic effects of repeated exposure
to increased cortisol levels what I called earlier the flatter the Furious having you know your body
holding on to cortisol for this extreme stress and then when it perceives stress it’s either
nothing or it’s extreme there are no kind sort of mild stressors out there that decrease hippocampal
volumes might also be a pre-existing vulnerability factor for developing PTSD the amygdala yet
another brain structure is the Olympic structure involved in the emotional process and it’s
critical for the acquisition of fear responses functional imaging of studies has revealed hyper
responsiveness and PTSD during the presentation of stressful script cues or trauma reminders but
also patients show increased amygdala responses to general emotional stimuli that are not trauma
associated such as emotional faces so they show an increased responsivity to things they see on the
TV that aren’t trauma-related to people crying to people showing anger’s going to have a
stronger emotional amygdala response than people without PTSD so clients with PTSD may be more
emotionally responsive across the board leading to more emotional dysregulation again an area that
we can help provide them with tools for early adverse experiences including prenatal stress and stress
throughout childhood has profound and long-lasting effects on the development of neurobiological
symptoms the brain is developing and if is exposed to a lot of stress and some of these excited toxic
situations how does that differ in the amount of damage caused versus a brain that’s already kind
of pretty much-formed programming may change for subsequent stress reactivity and vulnerability
to develop PTSD so if these happen during childhood or at any time the brain can
basically reprogram and go that it’s a really dangerous place out there so I need to hold
on to cortisol and I need to hold on to these stress hormones because every time I turn around
it seems like there’s a threat so I am going to be hyper-vigilant and respond in an exaggerated way
to protect you from the outside world adult women with childhood trauma histories have been shown
to exhibit sensitization of both neuroendocrine and Audino stress responses so basically they’re
showing hypo cortisol ISM a variety of changes take place in the brains and nervous systems of
people with PTSD and we talked about a lot of those the key take-home point is stress can
actually get toxic in the brain and cause physical changes not just thought changes in the brain
preexisting issues causing hypo cortisol ism where the brain has already downregulated whether it’s
due to chronic illness or chronic psychological stress increases the likelihood of the development
of PTSD this points to the importance of prevention and early intervention of adverse
childhood experiences we really need to get in there and help these people develop distress
tolerance skills understanding of vulnerabilities so they’re not going from flat to furious all
the time and so that they can understand why their body kind of responds and why they respond
differently than others and you know as we talk about this and of course I’m regularly bringing up
DBT buzzwords if you will think about your clients if you’ve worked with any who’ve had borderline
personality disorder what kind of history do they have did they have just a great childhood no we
know that people with BPD generally had pretty chaotic childhoods so this research is also
kind of underscoring why they may react and act the way they do that flat to furious people with
hypo cortical ism may or may not have PTSD so we don’t want to say well you’re fine if you don’t
have PTSD symptoms we do know that every trauma potentially can cause the body to down-regulate
and I kind of look at it as conserving a little bit more of the energy that it needs each time so
instead of conserving 60% now it’s conserving 65 and 66 each time it encounters a stressor in order
to prepare for potential ongoing threats in the environment hypercortisolism sets the stage for
the flattened the furious leading to toxic levels of glutamate upon exposure to stressors which
can cause the theorized reduction in hippocampal volume and persistent negative brain changes now I
always say the brain can you know rebalance itself and all well that’s part of the plasticity that is
the really cool thing about our brain however as far as regenerating those neurons I haven’t found
any evidence in the research that we found a way to help people regenerate once we’ve already those
neurons are gone they’ve been killed off the brain has to find a workaround so it does take time
but I do believe people can minimize some of the impact of the trauma they may have experienced
people with PTSD are more reactive to emotional stimuli even stimuli unrelated to trauma again
think about some of your clients especially if you work in a residential situation where you’re
around on 24/7, you know for 30 or 60 days, and you may see some clients that seem to get upset
over everything and you’re like ah such a drama queen or such a drama king and to yourself not
to anybody else but when you think about it from this perspective it gives you a different
perspective and you might say oh maybe their body responds differently they’ve got more emotional
dysregulation because of prior trauma they’re not trying to overreact this is their body’s response
because it’s perceived threat so many times it gives me a different approach to working
with that client hypercortisolism results when the brain perceives that continued effort is futile
feelings of fatigue set in akin to reduced stress tolerance so think about you know when you’ve had
a really long stressful period you know weeks or months maybe you’re dealing with an ailing family
member or something it’s just a lot of stress and you start getting really tired and when you’re
really tired and you’re worn down and somebody gives you one more thing it’s that one more thing
normally wouldn’t bother you but right now you just can’t take it so we can see how there’s a
reduced stress tolerance when somebody’s already at this stage reducing fatigue in our clients can
be accomplished in part with psychological factors including motivation or knowledge of other people
who are dealing with similar things support groups feedback about their and making sure they have
frequent successes not once a week but I want to have them keep a journal every day of something
good that happened or something positive that may indicate they’re moving forward in their
treatment goals and knowledge of an endpoint.Where are we going with this when is the treatment
going to end I don’t want most clients don’t want to be with us forever no matter how lovable
we are do you want to feel better and be done with us so having to help them see that there
is an endpoint we’re going to accomplish this goal this month and then we can reassess 46% of
people in the US are exposed to adverse childhood experiences so like I said this is a huge area
for early intervention where we can prevent people from developing PTSD later in life how awesome
would that be instruction and skills to handle emotional dysregulation including mindfulness
vulnerability prevention and awareness emotion regulation distress tolerance and problem-solving
could be wonderful additions to health curriculums anything any skills groups you do with children
or adolescents or even adults I mean just because they’re adults doesn’t mean that they’re safe
from PTSD or that they’ve crossed any threshold where they’re too old to learn we’re never too
old to learn of those exposed to trauma education about and normalization of their heightened
emotional reactivity and susceptibility to PTSD in the future may be helpful in increasing their
motivation for their current treatment protocol whatever it is but it also just normalizes things
so they don’t feel like they’re overreacting or they don’t feel guilty for being so tired
or whatever they’re experiencing right now are there any questions I know I went through
a lot of really complicated stuff but I thought it was really interesting not only the way
our brain reacts in order to protect us but how cross-cutting a lot of this stuff
was it not just PTSD we’re talking about necessarily but a lot of this information
applies to our clients with chronic fatigue burnout and chronic stress and we can
see that those people also are at risk at higher risk of PTSD should they be exposed
to trauma and none of us is immune I mean there are tornadoes there are hurricanes
there are you know things that happen that really stink so the more we can help clients
be aware of things develop skills and tools to prevent as much harm as possible I
think the more effective we are as clinicians depending on the client and I can do some
more research on the VA website because they’re really into medications for PTSD I
know ketamine which is a horse tranquilizer has been shown to be effective in people
with PTSD and there have been some others that have kind of given me pause ketamine
is a hypnotic you know most of the drugs they’re trying out right now are really in my
opinion they’re powerful drugs but a lot of them all of them that I know of have
pretty high addictive potentials too so they make me nervous but you know when you’re
weighing the when you’re going from a harm reduction model that’s not necessarily not
necessarily such the be-all-end-all I guess that’s interesting that you use ketamine in the ER it’s definitely powerful effective stuff and like I said earlier some of the
stuff that some of my clients and some people have seen done experienced I couldn’t even
imagine and you know sometimes for them to actually survive we may need to look at some
of these more intense more powerful drugs PTSD and veteran trauma is not are not my focus
right now and yes marijuana is being experimented with or looked at used whatever however you want
to look at it for PTSD treatment with veterans there’s pretty much not a drug out there they
haven’t tried to throw at it to see well what will this do I believe they were even using
LSD experimentally for a little while too you the VA I mean if you’re interested in this
topic let me see if I could pull that down into here, we go to the National Center
for PTSD US Department of Veterans Affairs has a lot of information if you go for
professionals, it has a ton more information if you can get on get some of your SI CEUs on
demand they do have some free CEUs for PTSD here I’ve never taken any of them but what
I’ve looked at when I’ve looked at like the PowerPoints the presentations and stuff I’m
sure they’re good so if you’re you do focus a lot on PTSD and you can get on-demand CEUs
then this might be a place to get some good free ones aside from DBT are there any other
evidence-based practices for therapy that you’ve seen work best in combination with the
medications cognitive processing therapy when you’re working specifically with veterans
and there is a free course on that too and this one I have gone through
and it’s really awesome CPT dot must seed and here I’ll just put it
into that education and this is a free course oops and here’s the other one ah golly everyone and
embryo does have a lot of research effectiveness with people with PTSD too so yes I would
definitely encourage people to explore all options alrighty everybody I really
appreciate you coming today and sticking with me through this topic and I will see
you on Thursday if you have any questions please feel free to email me or you can
always also send it to support that all CEUs com either way I get it and otherwise I
will see you on Tuesday thanks a bunch 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 Doctor Snipes by subscribing at all CEUs comm slash
counselor toolbox this episode has been brought to you in part by all CEUs
com providing 24/7 multimedia continuing education and pre-certification training to
counselors therapists and nurses since 2006 used coupon code consular toolbox to get
a 20% discount on your order this monthAs found on YouTube15 Modules Of Intimate Video Training With Dr. Joe Vitale – You’re getting simple and proven steps to unlock the Awakened Millionaire Mindset: giving you a path to MORE money, …
CEUs are available at AllCEUs.com this episode was pre-recorded
as part of a live continuing education webinar on-demand, CEUs are still available for this presentation at AllCEUs.com/counselortoolbox I’d like to welcome everybody to today’s
presentation of dialectical behavior therapy techniques emotion regulation we are going to
start by reviewing the basic premises of DBT and the reason we’re doing that we’re only
going to do it in this one because emotion regulation we’re starting kind of at
the beginning but we want to go over what is the theory underlying a lot of what we’re going
to talk about we’ll learn about the HPA axis and this isn’t something that Linehan talks about
in DBT but it is important for understanding our physiological stress reactions will define
emotion regulation identify why emotion regulation is important and how it can help clients ourselves
staff yay and we will finally explore some emotion regulation techniques there are things
besides just preventing vulnerabilities that we can provide to clients to help them regulate
their emotions before moving into that distress tolerance realm of skills and activities so basic
DBT premises everything is interconnected when you get up in the morning if you’re having a bad
the day you know you didn’t sleep well your back hurts you’re cranky you got a lot of stuff to do
it’s raining outside you know yay you’re noticing all the negatives your thoughts
maybe more negative you may be more likely to notice the negative you may be more likely to have
what we call commonly call a bad attitude if you start to have a better attitude what happens to
what you observe and we’ll talk about that in a little while the reality is not static what is true
right now in the present may not be true which is you know was the future from what
the present was half a second ago so reality changes when we look at a situation when we look
at an event, we’re looking at how am i reacting and what is my feeling about the situation right now
you know we can learn to change where we’re at but with the information, I have right now what’s
going on and a constantly evolving truth can be found by synthesizing different points of view
because most of the time as humans it’s just kind of part and parcel of being humans we don’t have
the whole picture and I did the best I could with these little graphics here think back if you will
to some of PJ’s experiments when he was trying to demonstrate egocentrism when we’re looking at
this yin and yang sort of model the girl’s stick figure what does she see if you ask her what
color is this orb she would probably say black because we’re assuming she sees the black side
if we ask this little thick figure model over here what color is the orb she’s seeing the white
side so he’d say white now if we asked a little confused guy who is standing kind of on the third
side or the south side he sees both of them so he hears the stick figure girl say it’s black he
sees a stick figure boy say it’s white and he’s going well it’s kind of both you can synthesize
both perspectives and figure out that this is an orb that has multiple colors even though she
can’t necessarily see those colors and he can’t necessarily see those colors so BBT says let’s try
to take a look and see if there are blind spots see if there are things we’re not seeing or things
we didn’t observe the basic assumptions of DBT and well people do their best if we didn’t think
that we probably wouldn’t be in this profession so people are doing their best with the tools they
have and the knowledge they have at any given time and I added that extra part people
want to get better and be happy most people don’t want to be miserable if it seems like they don’t
want to get better then we need to ask ourselves what is the benefit to staying miserable why is
it is scarier more threatening more awful to look at getting better or being happy and that’s one of
those motivational things we’re not going to go there today but in general people are going to
choose the most rewarding option when prevents presented with multiple options okay now this
one area in that I kind of diverge from the official statement is clients need to work harder and be
more motivated to make changes in their lives I’ve had a lot of clients who have been working their
butt off but they may not have the right tools it’s like trying to unscrew something that is
Phillips head with a butter knife they’re working hard but it’s not going anywhere because
they can’t get any traction so I crossed out the work harder and I tend to replace it with work
smarter clients need to work smarter they need to have more tools they need to have more effective
tools and some of the tools they have may be awesome if we just tuned them up a little
bit sharpen their oil and grease them whatever you need to do and be more motivated to make changes
in their life and you’re saying well they’re in therapy they’re coming here for whatever reason
there why aren’t they motivated to make changes well again let’s look back at motivation and what’s
the most rewarding choice is if they tried to make changes before and it hasn’t worked out and
they’ve been told that it was their fault they were being resistant or you know they were blamed
in some way or they just felt disempowered what’s going to make them motivated to try to do that
again please let me run the gauntlet most people don’t want to do that so we need to help
clients work smarter and understand that they are working hard and they need to continue to do so
and we’re going to help them get more effective tools and we need to help them get more motivated
we need to help them see that this time it’s going to be different maybe a little bit different
but this time we’re trying something new it may be different even if people didn’t create their
problems they still must solve yep you know if you grew up in a dysfunctional household you
didn’t create that problem but it is negatively impacting you today so you’re going to have to fix
it if you want to be happy which is the whole goal of the lives of suicidal or addicted
people are unbearable and when we’re talking about DBT we’re generally talking about people
who are highly emotionally reactive and suicidal self-harm those behaviors are away at this point
that they’re trying to figure out how to tolerate what seems like an unbearable situation in their
head addiction is much the same way it provides some relief from something they feel they have no
control over people need to learn how to skillful live skillfully in all areas of their life well
yeah because every area is interconnected if you’re stressed out at work do you just
leave work go home and you have not stressed out anymore no that’s not the way it works it would
be great if it did but it’s just not even if you don’t take all your stresses of work home with you
it has taken a toll on your energy level so when you get home you’re more vulnerable to emotional
upset or just fallen asleep on the couch at 6:00 p.m. Whatever it is so we need to help people
learn how to live skillfully in each area so the exhaustion or negativity or whatever it is
from one area doesn’t bleed over into the other area so we need to learn how to juggle stresses
in all of our areas to prevent vulnerabilities and people cannot fail in treatment when someone
relapses when someone you know backslides whatever word you want to use I look at it as a learning
the opportunity I say okay you made a different choice than we wanted you to make a different choice than
you were hoping you would make so let’s learn from and figure out why that was the most rewarding
choice than what was on your treatment plan the goal that you’re working toward why what
happened what were you more vulnerable so you didn’t choose the newer behaviors because they
weren’t as readily available let’s use this as a learning opportunity to figure out what’s going
on it’s not a failure it’s a learning moment or a teachable moment so what is emotion regulation
emotional dysregulation will start there results from a combination of high emotional
vulnerability so you’ve got somebody who is kind of reactive and extended time needed to return to
baseline so that when they get upset it takes them longer to de-escalate and get back to baseline
and an inability to regulate or modulate one’s own emotions so I want you to think about some
the time that you’ve been driving on the interstate and you’re just driving along cruising along and
heaven forbid if this has happened I hope not but if it did you’re probably just late a semi comes
along and runs you off the road onto the shoulder and oh my gosh you get onto the shoulder your legs
just to go in like this you can’t even press the gas pedal because you are so stressed out you’re
gripping your knuckles are white from gripping the steering wheel so tight your heart racing you’re
breathing fast you’re in full-out fight-or-flight mode so you went from a1 on the stress meter
you know kind of cruising along aware of the fact that you need to be cognizant of dangers to
a5 of oh crap that could have been bad alright so you take a couple of deep breaths you
your breathing goes down a little bit you get to the point where you can press the gas
pedal and you pull back out onto the highway now are you returning to baseline and just like
la-dee-da cutting around like you were before most likely not you’re a little bit more
on edge and you’re checking your bat rearview mirror more often you’re looking back making
sure nothing’s in your blood spot more awesome so you’re not returning to that same level of less
stress Tunis if you will you stay a little bit elevated because your brain is gone you know I
thought it was kind of a safe situation but I’m realizing now that not so much so I’m going to
keep you on higher alert and it’s going to take longer for you to return to baseline because
you’re looking for those threats now you’re much more aware that it could happen to people who
come from invalidating environment people who are regularly chronically stressed they’re constantly
looking around for anything else that is going to threaten them anything else that’s going to stress
them out so they’re not going from a 1 to a 5 back down to a 1 again they’re going from a 1 to a 5
back down to a 2 and then back up to a 5 and then now we’re only going down to a 3 it’s that
stress is ramping up so we need to figure out how to help people deescalate get back down to that
one and realize okay I got this that was an unpleasant situation but I got this now emotional
vulnerability refers to the situation in which an individual is more emotionally sensitive or
reactive than others or then they normally would be you know some people this is kind of and when
we’re talking about personality disorders this is pervasive when we’re talking about someone who
has been under a bunch of stress for six months this may be a situational sort of thing that we
need to help them figure out how to get out of but it may not be something that is completely
and utterly pervasive in any event when you are stressed you know you’re already kind of on edge
and something happens do you react the normal way that you normally would if you were just like
sitting there and going off oh well okay let’s figure out how to handle this or does it throw
you up sort of into the stratosphere and for a lot of people with emotional dysregulation when
they’re their relaxation is on the brink of chaos so they’re standing there teetering
and they’re going okay I cannot take one more wind or it’s going to push me over and then they
call them damp they get upset and they’re kind of on freefall for a while they get their balance
again but then they’re still right there on that precipice they never come down so what
we want to look at is what’s going on with these people that’s making them more reactive that’s
making them more alert and more hyper-vigilant to stresses and stressors some of these may be
because of differences in the HPA axis which play a role in making people more vulnerable or
reactive and we’re going to talk about the HPA axis in a minute environment of people who are
more emotionally reactive or often invalidating and what does that mean well pick Jane Jane
has had a heck of two years you know there’s just been death after death a job loss
she lost her home she’s living in an apartment right now but she’s not happy and you know yeah
you can just pile stuff on okay so James struggling right now she’s holding on and really
trying to do the next right thing she’s trying to make ends meet trying to do what’s right
by our kids just feeling stressed out and then something happens something that most of us
would react with it to you know it’s annoying but it wouldn’t throw us into utter chaos well James
on that precipice Jane’s already at a four maybe a four and a half depending on the day so when
this happened just that too puts her on a scale of one to five puts her at a
six-and-a-half which is in freefall but people may not understand that they may not understand
what’s going on in Jane’s life and they’re like this is not that big of a deal why are you just
overreacting which makes Jane feel guilty Phil is self-conscious and feels misunderstood so
then she feels isolated and rejected and we’ve talked about basic fears being rejection isolation
failure loss of control and the unknown well James kind of experiencing all of those right now and
the people around her instead of being validating and going okay you were already stressed out I
can see how this was just the straw that broke the camel’s back they’re going what is your
the problem so she doesn’t feel like she’s got social support she’s out there on an island unto
herself so we want to help Jane with emotional regulation because we know she’s up here and we
know she doesn’t like going into that freefall but how do we help her emotional regulation is the
ability to control or influence which emotions you have when you have them and how you experience or
express them and that’s a quote straight out of Linda hands book so emotion regulation prevents
unwanted emotions by reducing vulnerabilities so you can go through life you can go through
the day you can experience stress but instead of feeling overwhelmed or enraged you might feel
mildly irritated for a second and then choose to move on emotion regulation helps people learn how
to change painful emotions once they start so you don’t get stuck nurturing that emotion or feeding
into it and being angry with yourself because you got angry about something you have no control over
it teaches that emotions in and of themselves are not good or bad they just are it’s your brains
hardwired way of responding based on waiting for it the information that it has at this particular
point in time spiders if you’re afraid of spiders that is your brain’s way you see a spider and you
feel fear it’s your brain’s way of going threat spiders can be a poisonous big threat so you want
to get away from it that’s your body’s way your brain’s way of going let’s survive we want to do
this now you can figure out you can learn more about spiders so in the future when you encounter
then you realize that they’re not you know 99% of them are not threatening to humans but right now
at this moment your brain is saying warning getaway you probably want to do that so it teaches
that emotions internet themselves are just prompting us to do something they are survival
responses and suppressing them makes things worse telling yourself I shouldn’t feel afraid does that
do any good if your kid comes to you and tells you that you know I’m having a crappy day or I
hate this does it usually do any good to tell them well you shouldn’t feel that way feel better you
know just be happy does that work I’ve never had an experience where that worked now it may work
for some people but so we want to help people identify their emotions and not get consumed
by the emotions are effective when acting on the emotion is in your best interest so sometimes
it’s in your best interest expressing your emotion gets you closer to your ultimate goals sometimes
expressing your emotion gets you closer to your short-term goals like making the pain stop
and true pain is unpleasant however in the big scheme of things 15 minutes from now 3 hours
from now is that getting you closer to the goals that you want to achieve or was it just a
stopgap expressing your emotions will influence others in ways that will help you so if you want
to influence others in ways that are positive and will help you then emotions can be very kinder
that can be very helpful emotions are sending you an important message and we already talked about
that so I’m thinking the devil’s advocate amigos well I can think of a client that goes you rage
is a great emotion to express is it in my best interest yeah gets people to leave me the heck
alone does it get me closer to my ultimate goals yeah it reduces my stress by getting people to
leave me the heck alone will it influence others in ways that will help you, yeah it make them
go away and are these emotions sending you an important message yet rage is telling me that
these people like everybody are a threat to me so in the short term when you look at it that
way it can be tricky to see but we want to help people get outside of this immediate threat and
say where you want to be what happiness looks like to you or however you want to define
that ultimate goal and then once you get into distress tolerance was your Thursday talk about
how do you endure unpleasant emotions so you don’t take the stopgap route now on to our favorite
HPA axis the hypothalamic-pituitary-adrenal axis is our central stress response system and doesn’t
get too caught up and all the psychobiology of this I think it’s good to be cognizant of but
we’re not prescribing hypothalamus place in the brain release is a compound
called corticotropin-releasing factor or CRF which triggers the release of adrenocorticotropic
hormone from the pituitary gland which triggers the adrenal glands to release stress hormones
particularly cortisol and adrenaline now your adrenal glands are actually on your
kidneys and why is that important what I want you to see or understand is there are a lot of systems
involved there are a lot of hormones involved there’s a lot of stuff involved it’s not just box
you know you’re releasing a bunch of chemicals in your body that are altering the neurochemicals
and the other hormones to prepare you for spiders the adrenals control chemical reactions over large
parts of your body including the fight-or-flight response and produce even more hormones than
the pituitary gland so you’ve got these adrenals this is kind of your stress area if you will it
produces steroid hormones like cortisol which is a gluteal corticoid which means it makes your
body release glucose what we know is that glucose is blood sugar energy all right so it increases the
availability of glucose and fats for the long-term fight-or-flight reaction it also produces sex
hormones like DHEA and estrogen okay why is that important because we know that when estrogen
goes up serotonin availability goes up so if there are the adrenals are busy doing something
else it may cause other hormonal imbalances and it also produces stress hormones like adrenaline
that is going to ramp you up they’re going to increase your respiration increase your heart rate
all that kind of stuff so once you have that whole reaction we talked about and the perceived threat
passes cortisol levels return to normal great this is what happens in the ideal situation but what if
the threat never passes what if we’re working with a client who is constantly fearing rejection
and isolation they need external validation because they don’t feel good enough as they are
they don’t have social support because their emotional reactivity kind of pushes everybody
away so they’re constantly feeling this threat of rejection isolation failures loss of control
and the unknown they’re holding on just like you were holding on to the steering wheel after you
ran off the road and you got back on you know you kept chugging because you wanted to get to
your destination but you were scared witless okay so you’re chugging along what’s going
on what’s going on in that body the amygdala and the hippocampus are intertwined with the
stress response the amygdala modulates anger fear or fighter flight and the hippocampus helps
to develop and store memories when you’re under stress and think about a time when you are under
a lot of stress were you effective at learning and paying attention to the good things and the bad
things or were you just trying to make the pain stop and make the threat go away from the brain of the
child or adolescent is particularly vulnerable because of its high state of plasticity which is
why do we see people who tend to have personality disorders much of their trauma and stuff really
started early in their development and which is why it’s pervasive in every area or many areas
of their life, bad things are learned emotional upset prevent learning new positive things to
counterbalance it if you’re in a bad mood if you’re scared if you’re threatened you know if
you’re hungry homeless put whatever stuff is there are you paying attention to the
bluebirds that are flying around and singing pretty songs or are you paying attention
to the fact that you got an a on a test maybe not so, we need to understand this person who lives
in a chronically stressful environment may also have an overactive HPA axis so they’re already
they’ve already got some adrenaline and cortisol going on they live kind of in this state
of hyper-vigilance and then something happens and they’re just like through the roof kind of like
when you scare a cat what happens to the brain one is a chronic threat to its safety and a constant
the underlay of anxiety is constant undercurrent as it learns your brain forces synaptic connections
from experience and pruned away connections that aren’t utilized by people who feel a lack of control
over their environment are particularly vulnerable to excessive stimulation of the stress response
now it’s not just children abuse and neglected children pop right up there but abuse and
neglected adults think about a client you’ve worked with who’s been in an abusive relationship
for years does she have all the happy connections or is she pretty much terrified exhausted and
stressed out most of the time adults with anxiety or depressive disorders it doesn’t even
have to be an abusive or neglectful situation if you have someone that forever whatever reason has
clinical anxiety or depressive symptoms they are in this state of constant threat and constant of
people if you will so they’re not seeing they’re not able to learn and take in as much of the
good stuff so there’s more bad stuff coming in they’re paying attention to more of the bad stuff
or unpleasant stuff the synaptic connections that form the foundation of people’s schema of
themselves in the world become skewed towards the traumatic event at the expense of a synaptic
Network-based on positive experiences and healthy relationships so we had this client here and these
are her negative experiences she has a lot of them and she’s got these going through her head a lot
and it’s not they don’t just go away whenever she meets somebody and she’s like well they’re going
to leave me whenever something happened she feels isolated and alone she may fear so she’s got
really strong connections to those memories and past experiences and when you’re in the midst
of all this, there’s not a lot of happy stuff and even when she appears happy a lot of times she’s
faking it she’s not seeing and remembering all the happy stuff she just wants to avoid the pain
another example I could give you is thinking about a city planner now a city planner only has a
the certain budget just like we only have a certain amount of energy the city planner looks and says
what roads and what connections between cities get the most traffic and let’s devote our resources
and strengthen those connections because we know we’ve got all kinds of traffic going over there
and those roads that don’t travel those back roads we don’t need to pay much attention to
them right now because we need to make sure that those roads that are used the most are strong
but that’s the best analogy I can give without putting out strings and everything else but so
the hyper-vigilant state active IDEs activated by the stress response that disrupts our ability
to focus and learn you know we’re just trying to not die we’re trying to not be consumed by pain
it impairs the ability to form new memories and recall information due to the physiologic changes
in the hippocampus, it’s not time to learn and process and do all that kind of stuff have you
ever tried to study for a test when you had 16 other things going on that you are stressed about
how well did you remember this stuff over here sometimes people relate things to prior experience
well most of the time so maybe they’ve had a lot of dysfunctional relationships and they start to
get in a relationship which side is going to be triggered the negative memories are the positive
memories and then you have somebody who may be attached to some positive relationships they start to
get into a relationship and they remember some of the positives because there have been some really
good relationships but you know they may remember the negative too but most likely they’re going
to remember more strongly the positive so what’s their reaction going to be if we’re trying to help
our clients develop a healthy support system we need to help them address some of those highways
that are going towards the negative memories emotion regulation is transdiagnostic or useful
with many disorders it helps people increase their present focused emotion awareness it says right
now right here right now what are your feelings what are your physical sensations what are your
thoughts and what are your urges it helps people increase cognitive flexibility because it helps
the kind of step back and take a look and say okay what are my options let me step back from
being intertwined with this feeling and go okay I feel angry got it what are my options here what
do I usually do what I want to do when I’m on autopilot what are some other options I could
do that might help me move toward where I want to go identifying and preventing patterns of emotion
avoidance and emotion-driven behaviors we don’t want to get into the situation of constantly trying
to avoid unpleasant emotions by lashing out by hurting ourselves or by doing things reactively
when I feel this way I must smoke a cigarette I must cut myself I must fill in the blank we want
to help people find alternate ways and be able to step back and say that is an option is it the
option I want to choose today increasing awareness and tolerance of emotion-related physical
sensations sometimes these physical sensations are just so powerful and so overwhelming and
sometimes the rush of adrenaline and that foggy wibbly-wobbly feeling you get in your head when
you have just adrenaline coursing through your veins is so overwhelming that people don’t know
what to do with it and are afraid it won’t stop so let’s help them increase their awareness and
tolerance of this helped them understand that it passes and use emotion-focused exposure procedures
when they get upset help them think about things in the group sessions that get them a little bit
revved up you know we don’t want to precipitate a full-scale crisis or talk about something that
happened last week that got them upset and let’s apply these procedures emotional behavior is
functional to change the behavior it’s necessary to identify the functions and reinforcers of the
behavior so when they did it you know let’s talk about cutting because you know that is one of
those behaviors that we see are self-injury it’s what is the function of that behavior cutting
or self-injury is a way of inflicting physical pain where the person has control and they focus
on that and they feel a sense of mastery when the stuff going on in their head feels completely
uncontrollable and intolerable it diverts their attention and it also is something that they
they can control how much pain they’re in so that’s how it’s functioning now is the best
the response we want no but we can see why somebody might engage in that behavior and what reinforces that
behavior well when they do that not only do they get a reprieve from this emotional turmoil that
they don’t feel like they can touch or control or do anything with but their body also releases
endorphins release natural painkillers to kill that physical pain which makes them feel a little
a bit better so they’ve got kind of a double whammy on reinforcers there so we understand that
now we need to find something else that they can do and help them figure out how to tolerate
the turmoil emotions function to communicate to others and influence and control their behaviors
and serve as an alert or an alarm to motivate one’s behaviors so let’s talk about the first
one communicate to others so I’m communicating to a rat around me the people around me through my
emotions what’s going on if I’m angry I’m lashing out I’m going to influence people’s behavior and
they’re probably going to back off if I am sad or crying or scared that might bring them closer
and in a more supportive sort of thing you know again you’ve got to look at some of the behavior
self-injury can elicit a caretaking response but these emotions before somebody start
acting out the behaviors the emotions serve as a cue that okay Sally is getting ready to go in
free fall so they can start reacting sooner and it serves as an alert or an alarm to the person to
motivate their behaviors if they know you’re on the precipice if you know you’re right on the
edge of being vulnerable cranky being irritable that day can motivate your own
behaviors to figure out how to reduce some of your vulnerabilities and identify obstacles to
changing emotions now we can’t just say be happy and all of a sudden somebody’s like oh I
don’t know why I didn’t think of that I’m just going to go ahead and be happy that’s just not
how it works we want to look at organic factors do they have an organic long-standing chemical
imbalance of some sort and it may not be neurochemical it may be hormonal they may have too
much estrogen too much testosterone too little estrogen too little testosterone whatever let’s
figure out you know have them go see their doctor and figure out if there is something fibroids
or moans whatever that might be affecting their mood okay once we identify anything that we can
tweak there we can’t measure neurotransmitters we’re out of luck there because they’re found
in so many places in the body that there’s no way to isolate how much serotonin is actually
in the brain can’t do it yes we want to look at other factors that are biological imbalances
neurochemical imbalances that are caused by chronic stress that cause addiction to sleep
deprivation and nutritional problems so what sort of chemical imbalances are we precipitating
by keeping the stress going and keeping the adrenaline going keeping your body revved up
all the time we want to look at obstacles well let me stay with biological factors here real
quick the organic things if we can refer to the physician and we can figure out ways to address
those that give the person one step forward so they’re not feeling as depressed or they’re not
feeling as reactive people with hyperthyroid you know when their thyroid is overactive may have
some anxiety issues or some other mood issues that can be addressed with medication then we
Looking at situationally caused things is the ways we can help them reduce their chronic stress
sometimes there are some easy right-now sort of solutions other times but chronic stress comes
from issues that are so long-standing it’s going to take a while it’s not that we can’t do it but
it’s going to be a process so we move on and we say okay addiction we know that when people use
stimulants rev them up and then they crash and it makes them more than emotional yo-yo caused
by the substances or the addictive behaviors also makes them more vulnerable to emotional
reactivity sleep deprivation is all kinds of hormones out of whack and tends to make people more
irritable that’s one almost everybody can look at addressing right now and nutritional problems
if they’re not eating well not eating at all encourage them to see a nutritionist to
make sure they’re getting something balanced that they will adhere to not something that
they look at and go yeah that looks great but no way I’m eating nuts skill factors what can we help
they with we can identify cognitive responses that are obstacles which as I can’t do that
I won’t do that resistance in some way my response to that obstacle is set to look at it and weigh
the positives and the negatives do a decisional balance exercise to address the cognitive
responses and figure out why is the dysfunctional or unhelpful reaction more rewarding why is it
more rewarding to be angry or scared than to look at doing things and thinking of things that will
help you feel happier what’s the disconnect generally, it comes back to prior failures and fear of
failure because they’ve been down that road before and it’s such a letdown when they’re feeling
good for like three weeks and then they crash behavioral responses that are obstacles to
changing emotions if somebody lashes out when they get upset they lash out and throw things
and then they feel guilty so this behavioral response may lead to having more difficulty
changing emotions because we’ve got to help them figure out how to pause before the behavioral
the response so they don’t compound the situation with more negative emotions and environmental factors
people places and things being in environments where you’re surrounded by people who either agon
negativity or who bring out you know they’re there with you they’re talking about conspiracy theories
they’re just negative about everything or they’re critical of you or remind you of situations where
you’ve been criticized before so first, we want to help people identify and label emotions a lot
of our clients are relatively Alex Simon you know they have a small repertoire if any of
noting their emotions they just generally go from situation to reaction and label what they
felt is kind of a mystery so we want to help them and doing it retrospectively is fine at first
because that’s probably all you’re going to be able to get the event profiting the emotion what
were your thoughts your physical sensations and your urges help me describe this in enough detail
that if we were going to give it to an actor or an actress they could recreate the situation what
expressive behaviors were associated with that emotion you know did you cry did you throw
things did you hit the wall what were your interpretations of that event at the moment not
retrospectively but at the moment what were your interpretations of what was going on
what history before the event increases your vulnerability to emotional dysregulation lots
of big words what happened before that that already stressed you out or had you on edge
and you know we go through a whole bunch of different things and this is you know behavior
chaining we’re looking at kind of what led up to the event what made you more vulnerable and what
were you feeling at that time and then what were the after-effects of the emotion or the reaction
on your other types of functioning so after this event and you went into freefall and you got angry
and you lashed out and you screamed and you threw things how did that affect your work how did that
affect your relationships with your family how did that affect your mood and just generally your
sense of being in yourself for the rest of the day changing unwanted emotions okay so we started
labeling them we figure out what we’re feeling we figure out that yeah when we feel that way
we act in ways that you know make us feel worse afterward what do we do about it let’s change
All alright we already talked about the obstacles and we’re trying to address those but in a moment
check for facts ask yourself what are the facts for and against your belief if you believe that
someone did something to be antagonistic towards you okay what was their motivation what is the
facts for and against that also ask yourself is this emotional or factual reasoning am I making
a decision based on how I felt I felt attacked therefore I must have been being attacked or
facts you know I felt attacked yes but that was because this person said ABCDE and all of those
were very attacking and I felt like I needed to defend myself so those are to check the facts sort
of steps or you can go with problem-solving so let’s change the situation that’s called cause
any unpleasant emotion like I said with spiders at the moment you may not have enough information
to not feel scared but maybe your spouse loves hiking and camping and you want to go but
you’re afraid of those aren’t spiders so how can you change the situation so spiders don’t
trigger that same reaction increase knowledge increase exposure there are a lot of different
ways but problem-solving says ok what can I do so my reaction my correct reaction is not one of
threat or anger but it is one of at least mild acceptance prevent vulnerabilities which helps
reduce reactivity if you are a hundred percent you know you get up and you’re like this is going
to be a good day to day things that come your way are probably going to roll more like water off a
duck’s back then smack you upside the face like a mud pie so we want to prevent vulnerabilities from the turn
down the stress response because when you’re not when you’re not up here already then you know
you can fluctuate a little bit more and they help the person be aware of and able to learn and
remember positive experiences so if you turn down that vulnerability and somebody’s in a good place
or a better place than they were at least they’re going to be able to notice and we’re going to
want to encourage them to notice the positive experiences you know instead of thinking that all
people are threatening all people are going to hurt me all people are going to leave they might
notice that you know there’s Sally over here who’s worked here for 15 years with me and you know
she’s there she sometimes calls in sick but then she comes back she’s generally in a good mood
you know she’s not such a bad person and you start noticing some of the things that are
not self-fulfilling processes building mastery through activities that build self-efficacy
self-control and competence smuggle we don’t want to say you don’t want to set a goal
where somebody needs to go an entire week without having an emotionally reactive response let’s
say go for hours or maybe even a whole day that would be wonderful but first, we’ve got to talk
about how to reduce those vulnerabilities so we set the person up for success what things can you
do and well and we’re going to get down here in a minute what can you do if you wake up and you’re
feeling vulnerable you know the creepy crowds are going around they cancel school
for the entire week for school the county school system kids are off for an entire week
because of illness right now but you wake up in the morning and you’ve got a fever and a sore
the throat you’re like I don’t want to go to work and get out of bed today what can you do
to prevent being grumpy and overly reactive throughout the day’s mental rehearsal and this can
go for if you’re getting ready to do something scary or threatening seeing yourself do that and
do it successfully and this can even be during the day just envisioning yourself getting up and eating
your breakfast driving to work going through your day seeing that one person at the office that
always has some sort of snarky comment to say or whatever irritates you laughing at it or dealing
with it just fine going through everything in your day as you would like to see it happen envision it
see see what you can do rehearse it rehearse how to handle negativity you know if you know you’re
going to have to go in for your annual evaluation with your boss okay so mentally rehearse how it’s
going to go how are you going to react what’s going to happen so you’re prepared for it you have
your responses and it takes some of the unknown out of the situation physical body mind care pain
and illness treatment and the acronym for this is please I changed one of them to laughter
it used to be physical illness and that was both PNL but I like laughter anyway we’ll get there
when you’re in pain or when you’re sick you’re vulnerable to being a little bit cranky you know
that’s just because your body is already saying you are weak you know back in the day when you had to
defend yourself against predators the sick ones and the ones that were in pain were the ones
that usually got taken out first as a part of our brain that still remembers that for whatever
the reason so when we’re in pain or when we’re sick our body keeps that cortisol keeps our cortisol
levels higher and the stress response a little bit higher so we want to deal with those things but
know if we wake up and we’re in that situation moment that was a little bit more vulnerable
so we need to handle it with care and laughter you can’t be miserable and happy at the same time laughter
releases endorphins laughter helps people feel a little bit better and find something to laugh at
and have on my phone I keep comedy skits every once in a while I’ll just pop one in even if
I’m not having a bad day pop it in because I like to laugh eat two-sport mental and physical
health avoid addictive or mood-altering drugs or behaviors that are going to put you on that
the up-and-down roller coaster that goes up and it goes even further down than you were when you
started to get adequate quality sleep and exercise also helps increase serotonin and release
endorphins which help people be in a better mood mindfulness is a judgemental observation and
description of the current emotions we’re not going to go deep into this right now
another class on mindfulness and you can also google it remembering that primary emotions
are often adaptive and appropriate I know I said that like six times much emotional distress
is a result of your secondary responses shame over having it I shouldn’t feel this way anxiety
about being wrong you know maybe this is the wrong way to respond or you know what if
I’m wrong about this or rage doing due to feeling judged for feeling that way I feel this way
and you’re telling me I shouldn’t how dare you so mindfulness is kind of an exposure technique
because it helps people identify that yes I feel that way but it helps them learn to step back and
figure out how to not judge that and just go okay I feel that way better or worse whatever that’s how I
feel exposure to intense emotions without negative consequences that non-judgmental acceptance just
going all right is what extinguishes the secondary emotional responses of feeling guilty
about it or feeling ashamed or angry at yourself for being angry so think of it this way if you
can’t see this one’s the best Bruce Lee picture I could come up with scenario one is an unpleasant
experience the person has an unpleasant emotion and then feels guilt shame or anger for feeling that
an emotion so instead of having to deal with one emotion one-on-one now you’re having to fight for
different unpleasant emotions and you start acting to try to stop the avalanche of negativity in the
absence of adequate skills now Bruce Lee he was able to take out four or five at a time but most
of us you know we would be beaten because all of these adversaries would be coming at us and
we would be building on them in scenario two and this is where we want people to get they have an
unpleasant experience which is part of life they identify unpleasant emotions again part of
life is sucky but part but they can deal with one emotion they’re like okay I’m
angry what do I do about it instead of I’m angry what do I do about it and I’m guilty and you
see how you know she’s got this she can take that one emotion so what we’re helping people do is
uncomplicated this regulation is common to many disorders people with dysregulated emotions
have a stronger and longer-lasting response to stimuli yes they’re already kind of stressed
out they’re already hyper-vigilant if you want to say they’re already wound up a little bit and
then something happens and it amps for months now we have a scale of 1 to 5 if they’re already on
a 4 and it amps them up 2 points they’ve fallen off the scale they’re in freefall so we need to
understand that what we perceive as an excessive emotional reaction they may not have been starting
from the same place that we were, we’re starting from a 1 if they’re starting from a 4 you know
then their reaction to the same thing you seemed pretty reasonable emotional dysregulation is often
punished or invalidated and increases hopelessness and isolation emotional regulation means we help
people use mindfulness to be aware of and reduce their vulnerabilities so we help them take it so
they’re not at a 4 there may be a 2 you know they’re in therapy for a reason we’re going to
help them work on the other stuff and get them down to a 1 but right now let’s help them figure
out ways, they can take down their stress response take down their just underlying anxiety, and stuff
identify the function and reinforcers for current emotions when they happen was understand where
they came from because they’re functional do that chaining worksheet check for facts ok now that
I know how I feel I know what my reactions are I know what my thoughts are I know what my urges
are let’s check the facts in the situation for and against that forces people to kind of step
back which lets the urge sail out some and then problem-solves what can I do right now to improve
the situation and what can I do in the future so I don’t necessarily experience this exact
the same situation again how can I break that mold okay so emotion regulation doesn’t provide us
with a whole lot of distress tolerance skills, emotion regulation is really about preventing
vulnerabilities and helping people figure out okay here’s where I’m at how do I pause so then
I can choose from my disgust distress tolerance problem-solving or interpersonal effectiveness
skills but it’s a big step how awesome would it be if you could eliminate some of your
vulnerabilities and think about it just for a minute or two what vulnerabilities you’ve
got going on in you right now and how many of those you know could you potentially over
the next week or two kinds of address sleeping and eating maybe you have 16 things going on
and you could pare it down to eight there are a lot of different things that you might
be able to kind of pull out of the rabbit hat if you will and what kind of a difference
would it make if you’re talking to your staff and looked around at your organizational environment
what vulnerabilities are there environmental vulnerabilities physical vulnerabilities my best
friend’s working somewhere right now where pretty much everybody is required to work doubles because
they are so short-staffed they’re going to start getting vulnerable pretty soon so look around
what can you do to moderate that so they can model effective emotional regulation but they
can also not be emotionally dysregulated by a client who has emotional dysregulation issues all
right so that concludes our discussion today if you have any questions I would love to hear them
if you want to discuss that’s awesome if you want to get on to your next client you know I totally
understand that I want to wish everybody a happy Valentine’s Day for me I don’t particularly pay
a lot of attention to Valentine’s Day but it is the eve before half-price chocolates
and that is my kind of my kind a day you you you you if you enjoyed 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. Schneider I subscribing at all CEUs comm slash counselor
toolbox this episode has been brought to you in part by all CEUs calm providing 24/7
multimedia continuing education and pre-certification training for counselors
therapists and nurses since 2006 have used coupon code consular toolbox to get a
20% discount on your order this month.As found on YouTubeHi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…
this episode was pre-recorded
as part of a live continuing education webinar on-demand, CEUs are
still available for this presentation through all CEUs register at allceus.com/counselortoolbox I’d like to welcome everybody to today’s
presentation on trauma-focused cognitive behavioral therapy part 1 treating trauma and
traumatic grief in children and adolescents in this first part we’re going to define
trauma-focused CBT and talk about what we’re dealing with here because trauma-focused
CBT is a best practice and it is a manualized best practice so you’re going to learn about it
today but you’re not going to have enough skills where you can say you are certified in TF
CBT however I will provide your resources should you want to go out and pursue those so we are
going to talk about TF CBT as a best practice and implementing fidelity but I’m going to
also take a few detours and as I always do and talk about how this might be able be
useful with adults who have a history of trauma in childhood we’ll explore the components
of trauma-focused CBT and their intended functions, we’re not going to get through all of
those today but we’re going to start and we’re going to explore ways to use TF CBT with adult
clients so TF CBT works for children who have experienced any trauma including multiple traumas
so what we’re talking about is children who come to your office who are presenting with
trauma-related issues it’s effective with children from diverse backgrounds and works
in as few as 12 treatment sessions so a lot can be accomplished in 12 sessions they’re not
necessarily weekly sessions they can be spaced out a little bit part of it depends on the age
level of the child how long ago the trauma was any concurrent developmental or mental health
issues that might be present yada yada yada so it may be a little bit longer it may be a little
a bit shorter in terms of calendar time but you can also extend the number of sessions because
some of these things for example when they start talking about cognitive coping differentiating
between thoughts and feelings, some children take a while to get the hang of the
the nuance between the difference between thoughts and feelings so you might have to do two or
three sessions helped them to identify feelings and use the feelings thermometer this
has been used successfully in clinics schools homes foster care residential treatment facilities
and inpatient settings so there’s not an environment in which it can’t be used provided
that there is a supportive caregiver that can be of assistance obviously if you’re working with
a 10 or 11-year-old or a little bit younger or an older adolescent but you know any child who may
need some support outside of session we don’t want to be creating a crisis and then leaving them
kind of defend for themselves between sessions without some sort of emotional and cognitive
support so there must be a relationship that there is a bond if you will a
the rapport between the clinician and the caregiver who may not be the biological parent or the caregiver
and the child it does work even if there is no parent or caregiver to participate in treatment
however again we need to be selective about how we’re using that so if you have a child and
you’re going to use this particular approach and there’s no parent or caregiver to participate
it may be safer to use it in a residential setting or an inpatient setting where there is a
clinician somewhere where they can get emotional support because as you’ll see when we get into
the trauma narrative gets intense TF CBT is intended for children with a trauma history
whose primary symptoms or behavioral reactions are related to the trauma so if you’ve got someone
who has an unfortunate childhood but you think their behaviors may be more related to the peer group
maybe more related to conducting disorder or FASD or something else that may not be appropriate
because what we’re going to look at with TF CBT is reducing the PTSD symptoms the hyper-vigilance
avoidance behaviors etc as well as improving social skills and helping the person identify and
communicate their feelings and needs traumatic stress reactions can be more than simply symptoms
of PTSD and also present as difficulties with affect regulation we’ve talked before about how
people who are experienced who have experienced trauma may develop a situation where they are more
likely to experience emotional dysregulation the HPA axis kind of tightens up and holds on to the
stress hormones hold on to the stress reaction but then when it does perceive a stressor it goes
from 0 to 250 there’s no I’m going to get a little bit upset it is either nothing or it is a huge
mountain there’s no mole hills there so there may be problems with affect regulation there may
be problems in relationships because of difficulty trusting other people because of difficulties with
their self-perception and systems of meaning which you know we’re getting to in a few minutes but
the way they conceptualize the world because all of a sudden their world was turned upside down
somatization feelings coming out as physical symptoms so headaches body aches more illnesses
more days where they just don’t feel well and you know sometimes they just really don’t feel well
however, is it because of a bacteria or a virus or is it because of a stress reaction that is
kicking off all kinds of imbalances in hormones and neurotransmitters so we want to look at what
the effect are these traumas having on this youth or person and if we address this trauma and if we
help help them come to some sort of resolution or acceptance of the trauma and integration into
their world view of why this trauma happened and making meaning from it will help improve
these areas will help them reduce their hyper-vigilance etc and for many clients the answer is
yes and I talked earlier about the fact that this may be useful now it was designed for children
and adolescents but many of the adults I’ve worked with are very Alex thymic they are very unable
to identify their emotions their very unable to express their feelings sometimes they don’t even
know where their fear is coming from they’re just sort of paralyzed with fear and don’t trust the
world and they’re angry at everybody and if it comes from a traumatic experience then helping
them explore how that trauma is impacting them in the present can be useful in their
recovery process so these issues that TF CBT may help improve aren’t just limited to children and
adolescents they can present in adults who were traumatized as children and who didn’t develop
the skill to effectively deal with the trauma components of CBT TF CBT psychoeducation we’re
going to start by teaching them what they need to know about the trauma we’re going to talk about in
depth about these so I’m not going to detail them very much here parenting skills and if you’re
dealing with an adult oftentimes I will provide what I call reap Aron ting skills if your parent
were here or if your parent would have responded how you would have wanted how would they have
responded how can you do that for yourself now because sometimes you don’t have a significant
other or a caregiver with an adult client either but we want to help them figure out how to self
nurture if needed relaxation and stress management skills because some of the stuff we’re fixing to
talk about is going to be extremely distressful so you have some wiggle room if you will in terms of
what skills do you teach here they prescribe some but as far as relaxation and stress management affect
expression and modulation DBT skills seem to fit well into this framework for helping
people tolerate the distress not act on their impulses understand where the emotions are coming
from and preventing vulnerabilities and all that other stuff that can help them function outside of
session and when they’re not doing their homework help them feel like they’re able to focus on
something besides the trauma because we’re just kind of ripping the band-aid off that wound
at a certain point and they may have difficulty focusing on anything else likewise some children
and adolescents will come to you when that trauma is still relatively present and all they can think
about is that trauma or it regularly comes up for them and so we can help them learn skills so
they can start living more of what they might consider a meaningful life that’s not dominated
by memories of this trauma while we’re working through the process we want to give them a little hope
that there’s relief in sight cognitive coping and processing are provided next and enhanced by
illustrating the relationships among thoughts feelings and behaviors so initially cognitive
coping skills are taught and then all of this is going to be applied later as soon as we
get into the trauma narration helping the youth work through narrating the trauma and cope
with the feelings and thoughts that come up in vivo mastery of trauma reminders so any of those
triggers that are triggering flashbacks that are kicking off hyper-vigilant situations we’re going
to address as they come up in the trauma narration we’re going to help the person identify what it
is about certain situations that bring up this particular memory and how we master how to do
we deal with it and then finally conjoint Parent Child sessions and these don’t come till the end
all along the parents or the caregivers are participating in the process assuming there is a
parent or caregiver and understand learning a little bit more about what’s going on but we’ll
talk about what the clinician does in the parent sessions as well as what the clinician does in
the child sessions as we go through each stage effects of TF CBT reduction in intrusive and
upsetting memory so that’s awesome and you know if you think about what’s the function of these
intrusive memories a lot of times it is because either they haven’t been integrated into the
person’s schema of the world and well-being and or they still feel unsafe they have some cognitions
that is telling them they need to be alert they need to be aware they’re not safe so helping them
identify any cognitions and triggers that may be causing intrusive and upsetting memories
and addressing those again in the in vivo desensitization avoidance helping people reduce
their avoidance of certain situations and certain activities so they don’t feel like they are
confined basically to their prison it helps reduce the emotional numbing of a lot of people when they
go through trauma it’s so overwhelming and they’re so afraid if they feel they won’t be able to stop
feeling so they numb emotionally it’s protective it makes sense and as they develop the skills to
handle this and as they learn they can tolerate the distress of the memories of the trauma it
empowers a lot of clients there’s a reduction in hyperarousal depression and anxiety behavior
problems when you’re dealing with adolescents or children, especially ones who don’t have the
ability to articulate their feelings and their thoughts that are underlying these
feelings and how they relate to the trauma I don’t know many adults that can do that so
children typically act out physically to either protect themselves or try to get some
sort of protection comfort attention so they feel more secure so it’ll help reduce some of
that as we empower the child to identify what’s going on and articulate their needs more effectively
communicate with their parent and also deal with some of the stuff that’s making them still feel
threatened or afraid reductions in sexualized behaviors trauma-related shame interpersonal
distrust and again social skills deficits if a youth has been dealing with this trauma issue
for a while, they may have avoided other people because they don’t trust other people they’re
afraid of other people haven’t made sense of it so they may not have developed the social skills
that other youth have developed because they have been avoidant situations that might trigger
the trauma memories so who is is inappropriate for if the primary issue is defiant or conduct
disordered it if you don’t believe from a clinical standpoint that this is coming from a
the root of trauma history and addressing trauma is probably not going to do it now do these
children who are oppositional defiant conduct disordered have traumas in their history sure
probably they do but are those traumas causing the behavior or are those traumas sort of
irrelevant and one thing that you’ll find is a lot of we’ll talk about it more in a minute
a lot of people have multiple traumas but they may have resolved certain ones and be okay with
they but others are still open wounds don’t use it if the child is suicidal homicidal or severely
depressed if a child is in that particular state we don’t want to start poking the bear
especially in an outpatient setting but even in residential and even residential with adults I
was always extraordinarily cautious and hesitant to do any sort of trauma work in the first 30 to
60 days I had a client in residential substance abuse treatment I mean the first 30 days they’re
still kind of sobering up there are a lot of impulse issues and in the next 30 days there’s usually a
a lot of mood issues so I want them to feel like they’ve got a handle on things before we start
ripping band-aids off open wounds if possible and if you’re obviously if you’re dealing with a
a child the safety and ethics would just tell you when this might not be appropriate additionally
when children remain in high-risk situations with a continuing possibility of harm such as in
many cases of physical abuse or exposure to domestic violence some aspects of TF CBT may
not be appropriate for example attempting to desensitize to trauma memories is contraindicated
when real danger is present I took that verbatim from the TF CBT training or one of them
that is cited in your booklet or your class it is important to understand that not all of
these children are coming or existing living in an environment that is healthy and you may
have a parent who is court-ordered or ordered by child welfare to bring the youth to counseling
to address trauma issues but that child is going back to a chaotic situation so again it’s going to
be an ethical decision on your part once you have all of the training and you’ve become
certified and TF CBT it would be an ethical decision at that point whether or not to implement
the program to fidelity and you know we want to make sure that the child is cognizant
of any real and present dangerous challenges, they always come up, especially when you’re dealing with
families if the carrot parent or caregiver does not agree that the trauma occurred and we’ve all
dealt with this whether you deal with adults who were traumatized as children and they say nobody
believed me when I was a child and I tried to get somebody to here or whether you’re dealing
with a child right now who is with a caregiver or removed from a caregiver it doesn’t matter
but the caregiver was present at the time and the caregiver doesn’t believe the trauma occurred
it can be a huge barrier because that caregiver is not going to be able to be as supportive if the
The caregiver agrees the trauma occurred but believes that it is not affecting the child significantly
or thinks that addressing it will make matters worse then we can do some education here we can
identify symptoms that are coming out that are present which may be caused by the trauma and we
can show the research of TF CBT as well as other methods if you choose not to use TF CBT but you
can show the caregiver how addressing this trauma can mediate or mitigate some of those symptoms if
the parent is overwhelmed or highly distressed by his or her emotional reactions and is not
able to attend to the child’s experience so if the parent feels guilty for what happened or you
know such as in the cases of domestic violence the parent is dealing with their trauma
because they are surviving domestic violence they may not be able to attend to the issues of the
child at that point and it’s not a judgment it’s just how much energy you have and if you’re
trying to survive yourself you’re probably not going to be able to devote your full attention to
jr. Over here so we need to look at timing if the parent is suspicious distrustful or doesn’t
believe in the value of therapy again we can do some education here rapport building and go
slow if the client and I my experience has been this occurs when the client is court-ordered or
ordered by child welfare the parent does not trust the system and by the fact the system
referred them to you you’re part of the system so start low go slow try to be as compassionate
open and honest as possible I try with all of my clients but especially with my clients who are
involuntary I am very open about what’s in my records and what I write down because that could
go to the court which could you know potentially reflect upon them you know we talked about what’s
going in into the chart I don’t use subjective judgment everything’s objective unless we talk
about something and they say yeah I’ve made progress here or I feel like I’m backsliding here
and then we talk about how to how that’s going to be put in the notes I don’t lie I don’t cover-up
but I do want to make them feel more comfortable with what’s being written in that magic file that
gets stored away that nobody can see if the parent is facing many concrete problems such as housing
but consume a great deal of energy again if it’s a domestic violence issue and they’ve moved out
and they’re living in a homeless shelter or a domestic violence shelter the parents may be
exhausted and just not able to fully attend to the increased emotional and psychological demands
of the child during this therapy you know they’re going to be doing good to help junior through
the present crisis let alone anything else or if the parent is not willing or prepared to
change parenting practices even though this may be important for treatment to succeed and
there are few and far between situations where this may happen one of the situations would be
if you have a parent who is the biological parent and you have a boyfriend or girlfriend
who is abusing the child and you know that comes out and there needs to be some change in the
the way that children are introduced to new people or there may need to be some change in another
situation and how to indiscipline there are a lot of variations that may come up but ultimately
we need the parent’s full buy-in we need them to be willing to work with children on emotions
identification and cognitive coping and all this other stuff which ultimately ends up helping them
most of the time anyway because I don’t believe any of these skills can be harmful to a person at
At least the initial skills of the trauma narrative if it’s done inappropriately or incorrectly can be
very very harmful but we’ll get there specific strategies that can be undertaken through perseverance
in establishing the therapeutic alliance reach out to contact and try not to serve as the all-knowing
omniscient person but asking them what they need asking them what changed with jr. Asking them for
feedback and suggestions about what helps when jr. gets like this and so you can brainstorm put
the parent in the expert role of being the parent imagines that explore past negative interactions
with social service agencies or therapy not that we can undo that but we can make sure not to
repeat it and if they start acting disengaged we can evaluate the situation and come back and
say is this reminding you of that prior situation or you know are you feeling disempowered again or
whatever the case may be being fully aware that n TF CBT you have two very distinct clients plus a
the third one is the family so you’ve got a lot of different things to juggle if you want to explore
the parent’s concerns that may make them feel as if they’re not being understood or accepted
the lead listens to or is respected and that gets a little dicey sometimes especially when we start
talking about cultural sensitivity about belief about why the trauma occurred or a
variety of other things that we’ll talk about it’s important to be able to hear the parent and
come from a culturally sensitive and culturally informed perspective it’s also important if
the parent feels guilty for some reason you know and sometimes they will be cognizant of
any nonverbals or any statements that you make that might make them feel that way and if it comes
out or if there’s no other way to say it you know talk about any feelings they may have that about
being not believed or not respected and how can you best facilitate making them feel respected
and accepted and all that stuff explore and help them to come overcome barriers to participating
in treatment, if it’s transportation if it’s a job if it’s something else there may be some
brainstorming that’s required and a little bit of case management and I recognize that most of us
when we work in private practice or agency work don’t get any credit for billable hours for
case management but it has to be done in the best interest of the client and emphasize the centrality
of the caregiver’s role in the child’s recovery making sure that they understand that this can’t
succeed without their help by using parent sessions to reduce parent caregiver distress and guide them
through structured activities that empower them in interactions with the child so you’re going to
bring them in each week and you’re going to talk to the parent independently about what’s going on
what you’re covering how juniors behaving how you can help them help jr. Etc sometimes you need to
delay joint sessions until the parent or caregiver can offer the child support and sometimes that
means not even starting treatment really until the parent and caregiver parent or caregiver
can be on board now you can get started with psychoeducation emotions identification feelings
identification and stress management and coping skills you know there were not really
poking a bunch of bears so you can probably safely get started on that if it’s sometimes it’s
court-ordered and they have to start treatment by April 1st or something so there are things you can
do but you may need to delay the actual beginning of the trauma narrative until the parent is
able to be available to educate everybody on how therapy works and instill in everyone not just
the parent optima optimist that well optimism about the child’s potential for recovery you
know sometimes they’ve been dealing with this child’s acting out behaviors for so long they’re
just like you know we’ve already been to three other therapists I don’t know what’s going to
fix it or I’ve done everything I know how to do good luck so we can talk about you know a
different approach or we can talk about what they’ve done that’s worked for a short period
of time and build on those strengths to instill optimism and hope and empowerment so
initially, when we talk about psycho-education it’s important to provide accurate information
about the trauma when children are traumatized they can be confused and not completely understand
what happened they may blame themselves and they may hold on to myths because they’ve been misled
and/or deliberately given incorrect information so one of the best ways we can help is to correct
that information provides information about how often this happens and whether you know it’s okay
to do this that or the other psychoeducation clarifies inappropriate information children may
have obtained directly from the perpetrator or on their own so the perpetrator may have told them
that this is how I express love or this is how you need to be disciplined because you don’t learn
this is how I was disciplined whatever it is or they could have gotten it on their own they could
have gotten it from school from the internet or just come up with it in their little heads trying
to make sense of what happened psychoeducation also helps them identify safety issues the
difference between safe situations and dangerous situations and as we get through this I really
want you to get away from the notion that TF CBT and childhood trauma are only physical and sexual
abuse there are so many other traumas as evidenced by the adverse childhood experiences survey that
I want you to wrap your head around that and there are things they didn’t cover in the aces such as
bullying and natural disasters so we want to help children whatever the trauma is the trauma made
they feel unsafe so we want to identify safety issues if the trauma was a hurricane then we want
to talk about what hurricanes are how often they hit what to safety plan etc so every time a
the thunderstorm comes they don’t freak out and we want to use psychoeducation to provide another
way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about
the traumatic experience you know it makes sense that that was scary and makes sense that
you’re angry it makes sense that you feel this way and we can talk about why that makes
sense and why it makes you feel that way through cycle education you’re getting the child to start
talking about the specific trauma that he or she experienced in a less anxiety-provoking way by
talking in Jen wrong about the type of trauma so you’re talking about natural disasters you’re
talking about plane crashes you’re talking about domestic violence so they start learning about
it and then eventually you’re going to move down to their experience with it so like I said there
are a ton of different traumas and the ACE study even acknowledges that these are just the ten most
common ones that they heard however there are many many many different traumas and types of trauma
some of the biggest ones are physical and sexual abuse physical neglect emotional abuse
and neglect and the Aces identified mother treated violently I would say anyone in the household
treated violently it’s not just the mother’s substance misuse within the household and that
can be by the parents or by siblings household mental illness parental separation or divorce and
an incarcerated household member so those were aces but then like I said there’s also bullying
the death of a parent or sibling is extremely traumatic hurricane tornado natural disaster and
then I put the fire out separately because sometimes fire can be man-made sometimes it can be a wiring
problem but sometimes it can be Jr was playing with matches now even if jr. Accidentally started
the fire does that make it any less traumatic no it probably makes it more traumatic because then
there’s a whole sense of guilt and responsibility but it’s still a trauma that has to be dealt
with so I put a link to the adverse childhood experiences website if you want to go look more
about that but we’re going to move on psycho-education involves specific information about
the traumatic events the child has experienced not the child’s event we’re not going to go
into police records or something, we’re just going to talk about specific information about
domestic violence or whatever body awareness and sex education in cases of physical or sexual
maltreatment and there are caveats for getting parental consent and permission and all that other
stuff and Risk Reduction skills to decrease the risk of future traumatization now going back to
those other things it’s not just about physical or sexual abuse so we want to look at what was the
the risk created by you know how can you reduce your risk of being bullied how can you reduce your
risk of being traumatized in a tornado you know you can’t stop the tornado from coming
and they’re everywhere so what do you do and talk about a safety plan the same thing with fire
information needs to be tailored to fit a child’s particularly particular experiences and level
of knowledge obviously, you’re going to provide different information to a seven-year-old than
you are to a 17-year-old provide caregivers with handout materials to reinforce the information
discussed in session so this may help educate the parents about some of it but it lets them
know what you talked about and it gets us all on the literal same page you’re providing them a
handout of everything you went over with Junior and we want to encourage caregivers to discuss
this information at home reinforces accurate information about how safe or unsafe they
are and obviously, we’re going towards safe and reinforced accurate information and develop
a safety plan so they feel confident that at home they’re going to be taken care of when you
start psychoeducation you do want to get a sense of what the child already knows and you can use
a question-and-answer game format in which the child gets points for answering questions which I
love this suggestion so you can ask them if you know what is a hurricane or is a tornado and see
if they know and see if they know how much time and much-advanced warning we have for a tornado
versus a hurricane or you know whatever situation you’re talking about you see I did a lot of posts
Hurricane Katrina counseling in northern Florida so that’s one of those things that comes up for
I am talking with children about how likely is it that a category 5 hurricane is going to hit
again but encouraging them to give your aunt’s give answers and if they give the wrong answer you
know it’s great to try now you know try to coach them into a correct answer or provide them the correct
one but give them credit for at least making an effort sample questions might include what is
you know and put in the type of trauma what is bullying how often do you think bullying happens
and why does bullying happen you know those are some questions you can ask to just open a dialogue
about bullying, if this child has been a victim of bullying and is and is traumatized so cultural
considerations meet the child and family where they are by presenting information in a way which
they can relate it to their belief system and you may need to consult with their spiritual
guidance guides leaders whether it be a pastor or you know whatever to get some guidance
on how to handle certain aspects of whether it was the will of God and in the case of sexual abuse
how to handle the concept of virginity and how to handle the concept of bad things happening to bad
people and whatever else they think is coming from or their parents are instilling in them in a
belief system we want to make sure that we’re not necessarily contradicting it and going oh mom dad
and the church is wrong but we also want to help them try to integrate this in a way that can help
they have strong self-esteem so reaching out to those spiritual leaders and the family asking what
their belief system about certain things can be very helpful assess the general beliefs about
the trauma if something happened or when something happens ask the parent or the family that’s there
not necessarily the child but you want to get a sense of what the family stance is on why this
happened what it means how it’s going to impact life hence foreign henceforth and forever more
focus on the events they perceive as traumatic to the family but most especially the child if the
child’s going back to the Aces you know maybe the parents got divorced but the child doesn’t
see that as traumatic because there was domestic violence ahead of time the domestic violence was
traumatic the divorce was a relief so wherever the child is with each trauma we want to
be respectful of what they perceive is traumatic and tailor the information so the family can be
more receptive to it as supportive as possible and sometimes you need to make sure that the language
you know make sure the language is not jargony about general views of mental health and mental health
treatment should also be assessed and addressed in the psychoeducation piece not only with the child
but also with the family, if they are suspicious of it don’t understand it think that you’re just
going to magically fix Junior we want to demystify the process and talk about what is the purpose of
the assessment what is the purpose of each one of these activities and why am I doing this or why
are we doing this as a team and how can it help and then we also want to provide information to
D stigmatize and normalize mental health issues and seeking treatment some cultures are still
resistant to seeking treatment and I use the term cultures broadly because there’s
a stigma associated with it so normalizing for them how many people go to treatment how common
PTSD is or whatever the situation you’re dealing with it doesn’t mean they have to like it but at
At least it will give them a little bit of a nugget to understand that they’re not the only ones if
they are from a cultural group a minority cultural group of some sort you might want to provide
information about how common this particular issue is in their group I’ve done a lot of work
with law enforcement and emergency responders and they’re kind of their little group so
we talk about how common depression is among law enforcement and emergent emergency responders
specifically, because they face so much so many different stressors than you know Joe Schmo over
here so it D stigmatizes and normalizes a little bit now they still may not talk about it and
go well hey you know 37% of us have clinical depression no that’s probably not going to happen
but at least in the back of their mind, they can go you know what I’m looking around this room and
I can bet that at least one other person’s on antidepressants or something and feel a little
less unique and isolated in parent sessions you want to provide a rationale and overview of the
treatment model educates parents about the trauma and talks about the child’s trauma-related symptoms
so we’re going to go over what is hyper-vigilance what is the function it why people become
hypervigilant after trauma and what might it look like in a child because it presents very
differently for different children so we might want to give some ideas and say does this sound
like Johnny or does this sound like Johnny and help them understand why these behaviors may
be coming out we want to talk about how early treatment helps prevent long-term problems okay
maybe the trauma happened three years ago but still, it’s better than waiting ten more years and
you know Johnny’s still not having any Ellucian will want to talk about the importance of talking
directly about the trauma to help the children cope with their experiences and not hedging and
this will be on a case-by-case basis but the manual walks you through handling this discussion with
the parents about exactly how much detail do I go into if Johnny brings it up at home reassure
parents that children will first be taught skills to help them cope with their discomfort
and that talking about the trauma will be done slowly with a great deal of support so we’re not
just going to plop them down and go okay and tell me about the day that all this happened which
is what the child has experienced already if it was reported to law enforcement and/or the child
welfare they’ve probably had somebody sit down and say get right to the nitty-gritty at least
once or twice and it’s completely dehumanizing so we want to reassure parents that we’re not
going to do that to the child again will help the caregiver understand their role in the child’s
treatment since this modified since this model emphasizes working together as a team so I’m not
just going to be educating you it’s not going to be a parallel thing where I go in and I work with
Johnny and then I tell you what I did and then I work with Johnny I’m going to work with Johnny
and then we’re going to discuss what Johnny and I did in session and I’m going to get input from
you and we’re going to talk about how you feel about it and then I’m going to provide you with tools
so you can help Johnny outside of the session because you’re going to be with them for six-and-a-half
other days that I’m not and this can’t work if it’s just one hour once a week and we want to
elicit parent input questions and suggestions as much as possible because they’ve been living with
their kid for you know however many years so they probably have an idea about what works and what
doesn’t so we’ll start with both parents and children in their respective sessions helping
them understand what control breathing is and how it helps slow the heart rate and trigger the
wrist and digest sort of reaction in your body when your breathing slows your heart naturally
slows because the stress reaction tells your brain you’ve got to breathe fast and the heart
rates got to go fast well when you override that then you’re kind of overriding the whole system
and we’ll also talk about thought stopping and this is especially helpful if the trauma is recent
or and/or ever-present in the mind of the youth so they can say I am NOT going to talk about that right
now I’m not going to think about that right talk about distraction techniques go back to
your DBT stuff talks about improving the moment and accepts to help the child develop skills to
handle and work through when those thoughts pop up replace unthawed unwanted thoughts with
a pleasant one so talk about it in session when thoughts like that come up what would you
prefer to think about and then really get into the Nitty Gritty the five senses what do you see
smell hear taste you know help me get into that situation or that thought this teaches that
thoughts even unexpected and intrusive ones can be controlled so that gives them hope and again we’re
not exacerbating the thoughts right now we’re not bringing up their particular trauma and
having them get into detail we are just helping them deal with what’s happening normally on a
day-to-day basis so they feel like they have more control for the older kids you can have them
people log about when this technique is used what they were thinking about and how effective the
thought stopping was and then review it and help them tune it up if it’s not really effective and
give them praise for when they use it effectively relaxation training persons of Asian or Hispanic
origin tend to express stress in more somatic or physical terms so just be aware of that but that
doesn’t mean that Caucasians don’t relaxation training is good for anyone and the medical
school of South Carolina training recommended that relaxation is stress-free and
workbook by Davis Schulman and McKay so and it is still in publication when deciding how to
present relaxation techniques are creative have the child help you to integrate the elements
into the technique that makes it more relevant to them so, what are you thinking about when you
relax you know I know I like to go to the woods but maybe this kid likes to think about a video
game or play with their dog whatever it is but helps them make it relevant to them and then have
they identify other things they do to relax like drawing listening to music walking and making a
list of those things so they can refer to it when you’re teaching relaxation training especially if
you’re doing something like progressive muscular relaxation be sensitive to the child’s wishes if
they don’t wish to close their eyes or lie down which could trigger memories of the trauma we’re
not going there yet so if they feel vulnerable lying down or taking orders like that because
you can imagine how being told to lie down and close their eyes might be a trigger for certain
abuse survivors you know be cognizant of that and say you know get into a comfortable position
or how where would you like to sit while we talk about this like I said parents can often
benefit from the relaxation training as well so because they’re dealing with their issues
about the trauma but they’re also dealing with trying to figure out how to help Johnny and any
of them deal with any of Johnny’s misbehaviors or problematic behaviors then they move on to
feelings identification so it helps the therapist judge the child’s ability to articulate feelings
if you can tell me what makes you happy that’s great but if you can’t then you know we need to
work on figuring out what makes you happy you also want to help the child rate the intensity
of the emotion don’t let them stick with happy mad sad glad and afraid you know let’s talk about
different emotions and use the emotion chart with little faces on it or you can use the emotion
thermometer so is it a hot emotion or is it a cool emotion and helps the child
learn how to express feelings appropriately in different situations I mean sometimes they’re
going to be angry but it might not be appropriate to you know get up and stomp out of the room or
whatever however they communicate it so help them figure out how to articulate that so they can be
heard and supported some children have difficulty discussing or identifying their feelings so
you might try stepping back and discussing the feelings of other children or characters from
books or stories so you know think about Puff the Magic Dragon if they’ve read that you know
that dates me a little bit there but you know how did the little boy feel and talking about things
different characters and different stories where there are elements of anger and shame and loss and
all of that stuff helps children identify how they experience emotions if they seem detached
from the experience because sometimes they just they’ve shut it off it was just too overwhelming
so we want to talk about you know when you’re happy what does that feel like or when you’re
angry what happens what does your body feel like when you’re angry and they might be able
to tell you they hear their heartbeat in their ears or everything gets all fuzzy or whatever
but help them start tuning in to how they react and connecting that with an emotional word and then
after all, that’s done they can identify feelings they can identify feeling intensity now we want to
differentiate between thoughts and feelings many children describe thoughts when they’ve been
asked about a feeling so if you ask them how they feel they may say I want to run away so
you want to say okay well I hear that you want to run away so I’m wondering if you are bored and you
you’re bored and want to get away from it or if you’re scared can you tell me a little bit more
about what it means to you to want to run away during feelings identification the parent
sessions normalize what is going on with their child and help the parent understand that some
children may be seemingly in constant distress or detached from the trauma and that’s okay
we all react differently to traumas so again we’re going to share with the parents what we’re
Do let them know any specific difficulties if any juniors have encouraged the parent to praise
the child for appropriate management of difficult motions and I put in parenthesis successive
approximations because they’re not going to get it a hundred percent right every time so if they
try to effectively manage their emotions even a little bit let’s give them praise for that and
then help them figure out how to do it a little bit better the next time so instead of having a
complete meltdown maybe they got up and stomped out of the room well that’s an improvement so
then we want to talk about how to shape that behavior so it’s a more appropriate communication
if parents have difficulty identifying their own emotions provide them with examples so
continually ask them questions about how you feel when it’s a rainy day outside and how to do you
feel when somebody’s supposed to call you and they don’t how do you feel when and have about 15 or 20
examples and you can have them on a piece of paper and even give it to the parent to take home for
their homework if parents are overcome with their own emotions about the trauma validate
their feelings and explain how children need to see that their parents can handle talking
about the trauma so there the children need to see the strength and the parents which is what you’re
going to work on in parent sessions to make sure that the parents have the resolve and the skills
handle talking about this topic with junior TFC BT can be an effective intervention
for children or adolescents whose primary presenting issue is trauma-related emotional or
behavioral dysregulation TF CBT is not appropriate for clients who are actively suicidal and severely
depressed or currently abusing substances we want to make sure they’re clean
and sober as much as possible TF CBT starts with psychoeducation and then teaches stress
management and coping skills to aid in the management of distressing feelings psycho IDI
helps to clarify the inappropriate information children may have and start getting them a little
a bit more comfortable talking about the topic in general before we start going deeper and
feelings identification helps participants start effectively labeling and communicating their
feelings so they can receive the support and nurturance they need from their caregivers
and their support system 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 to all CEUs comm slash counselor toolbox this episode has been brought to you in
part by all CEUs calm providing 24/7 multimedia continuing education and pre-certification
training to counselors therapists and nurses since 2006 use coupon code consular toolbox to
get a 20% discount on your order this month.As found on YouTubeAlzheimer’s Dementia Brain Health ➫➬ ꆛシ➫ I was losing my memory, focus – and mind! And then… I got it all back again. Case study: Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it.
Which means the brain’s
ability to adjust and adapt as well as learning and memory so these are good receptors I like
them glutamate binds with these receptors and high levels of glutamate are secreted during high
levels of stress glutamate remember is what GABA is made from but high levels of glutamate
it’s an excitatory neural net in the brain and overexposure of neurons to this glutamate can be
excited toxic and may contribute to the loss of neurons in the hippocampus of patients with PTSD
so we’re actually seeing brain volume decrease as a result of exposure to certain chemicals elevated
gluten core glucocorticoid and yeah glucocorticoids increases the sensitivity of these receptors so
you’ve got a bunch of glutamate being dumped and you’ve got a bunch of glucocorticoid you’ve got
cortisol in there making these receptors more sensitive so it’s got they’re more sensitive and
they’ve got more coming in which makes it a whole lot easier to become toxic and start causing
neuronal degradation what does that mean why do we care it may take clients with PTSD more time to
master new skills because of emotional reactivity but also because some of their synaptic plasticity
may be damaged so it may take them a little bit longer to actually acquire and integrate these
new skills it’s not saying they’re stupid they can remember it just fine however when they’re
an emotionally charged state and helping their brain learn that okay this isn’t a threat that’s one
of those sort of subconscious things that has to happen that can take longer if the brain becomes
excited toxic during stress inhibited learning and memory then it becomes excited toxic during
stress which inhibits learning and memory so it’s under stress things are excited toxic neurons
are starting to disappear so I’m wondering and I’m just hypothesizing here I don’t know the
answers obviously or I wouldn’t be practicing it but what happens during the exposure therapies
because that’s exactly what we’re doing is we are flooding the brain with all of these chemicals
and creating basically an excitotoxin now they found some evidence that exposure therapies can
be helpful according to the DOJ website but or not the DOJ I can’t even think of it right
now the VA website but you know I’m wondering long-term what the impact is endogenous opioids
natural painkillers act upon the same receptors activated by exogenous opioids like morphine and
heroin exerts an inhibitory influence on the HPA axis well we know that people take opiates
and it has depressant effects on them it slows them down and calms them down alterations in our
natural opioids may be involved in certain PTSD symptoms such as numbing stress-induced analgesia
and dissociation again think of any clients you’ve had who have been abused or even taken and not like
the side effects of opiates are what opiates do to some people make them feel more relaxed stress
induced and analgesia they don’t have as much physical pain sometimes they just it’s there
I don’t care pill another interesting factor is now truck zone which is used to oppose opiate
appears to be effective in treating symptoms of dissociation flashbacks in traumatized persons so
basically, they’re saying if we undo the endogenous opioids we can treat these symptoms it highlights
the risk of opiate abuse for persons with PTSD though because if endogenous opioids produce
some of these numbing symptoms and dissociative symptoms so they can get away from the pain and
the flashbacks then if they add to that you know oral opioids it could prove to be a very tempting
cocktail we do want to as clinicians figure out how we can assist them with their physical and
emotional distress tolerance so they don’t feel the need to numb and escape and you know I
can’t imagine what some people have seen have gone through and I’m not trying to take that away
from them, I’m trying to help them figure out how they can stay present and learn to integrate it
changes question marks in brain structure and one of the questions that’s come up in the research is
because there aren’t any longitudinal studies that looked at it was the hippocampal volume as low to
begin with which created a predisposition for PTSD or did PTSD create the smaller hippocampal volume
interesting hippocampus is implicated in the control of stress responses memory and contextual
aspects of fear conditioning so it helps you to find these triggers in the environment that
help you become aware with your senses about when there might be a trauma prolonged exposure
to stress and high levels of glucocorticoids damage the hippocampus we’ve talked about that
hippocampal volume reduction in PTSD may reflect the accumulated toxic effects of repeated exposure
to increased cortisol levels what I called earlier the flatter the Furious having you know your body
holding on to cortisol for this extreme stress and then when it perceives stress it’s either
nothing or it’s extreme there are no kind sort of mild stressors out there that decrease hippocampal
volumes might also be a pre-existing vulnerability factor for developing PTSD the amygdala yet
another brain structure is the Olympic structure involved in the emotional process and it’s
critical for the acquisition of fear responses functional imaging of studies has revealed hyper
responsiveness and PTSD during the presentation of stressful script cues or trauma reminders but
also patients show increased amygdala responses to general emotional stimuli that are not trauma
associated such as emotional faces so they show an increased responsivity to things they see on the
TV that aren’t trauma-related to people crying to people showing anger’s going to have a
stronger emotional amygdala response than people without PTSD so clients with PTSD may be more
emotionally responsive across the board leading to more emotional dysregulation again an area that
we can help provide them with tools for early adverse experiences including prenatal stress and stress
throughout childhood has profound and long-lasting effects on the development of neurobiological
symptoms the brain is developing and if is exposed to a lot of stress and some of these excited toxic
situations how does that differ in the amount of damage caused versus a brain that’s already kind
of pretty much-formed programming may change for subsequent stress reactivity and vulnerability
to develop PTSD so if these happen during childhood or at any time the brain can
basically reprogram and go that it’s a really dangerous place out there so I need to hold
on to cortisol and I need to hold on to these stress hormones because every time I turn around
it seems like there’s a threat so I am going to be hyper-vigilant and respond in an exaggerated way
to protect you from the outside world adult women with childhood trauma histories have been shown
to exhibit sensitization of both neuroendocrine and Audino stress responses so basically they’re
showing hypo cortisol ISM a variety of changes take place in the brains and nervous systems of
people with PTSD and we talked about a lot of those the key take-home point is stress can
actually get toxic in the brain and cause physical changes not just thought changes in the brain
preexisting issues causing hypo cortisol ism where the brain has already downregulated whether it’s
due to chronic illness or chronic psychological stress increases the likelihood of the development
of PTSD this points to the importance of prevention and early intervention of adverse
childhood experiences we really need to get in there and help these people develop distress
tolerance skills understanding of vulnerabilities so they’re not going from flat to furious all
the time and so that they can understand why their body kind of responds and why they respond
differently than others and you know as we talk about this and of course I’m regularly bringing up
DBT buzzwords if you will think about your clients if you’ve worked with any who’ve had borderline
personality disorder what kind of history do they have did they have just a great childhood no we
know that people with BPD generally had pretty chaotic childhoods so this research is also
kind of underscoring why they may react and act the way they do that flat to furious people with
hypo cortical ism may or may not have PTSD so we don’t want to say well you’re fine if you don’t
have PTSD symptoms we do know that every trauma potentially can cause the body to down-regulate
and I kind of look at it as conserving a little bit more of the energy that it needs each time so
instead of conserving 60% now it’s conserving 65 and 66 each time it encounters a stressor in order
to prepare for potential ongoing threats in the environment hypercortisolism sets the stage for
the flattened the furious leading to toxic levels of glutamate upon exposure to stressors which
can cause the theorized reduction in hippocampal volume and persistent negative brain changes now I
always say the brain can you know rebalance itself and all well that’s part of the plasticity that is
the really cool thing about our brain however as far as regenerating those neurons I haven’t found
any evidence in the research that we found a way to help people regenerate once we’ve already those
neurons are gone they’ve been killed off the brain has to find a workaround so it does take time
but I do believe people can minimize some of the impact of the trauma they may have experienced
people with PTSD are more reactive to emotional stimuli even stimuli unrelated to trauma again
think about some of your clients especially if you work in a residential situation where you’re
around on 24/7, you know for 30 or 60 days, and you may see some clients that seem to get upset
over everything and you’re like ah such a drama queen or such a drama king and to yourself not
to anybody else but when you think about it from this perspective it gives you a different
perspective and you might say oh maybe their body responds differently they’ve got more emotional
dysregulation because of prior trauma they’re not trying to overreact this is their body’s response
because it’s perceived threat so many times it gives me a different approach to working
with that client hypercortisolism results when the brain perceives that continued effort is futile
feelings of fatigue set in akin to reduced stress tolerance so think about you know when you’ve had
a really long stressful period you know weeks or months maybe you’re dealing with an ailing family
member or something it’s just a lot of stress and you start getting really tired and when you’re
really tired and you’re worn down and somebody gives you one more thing it’s that one more thing
normally wouldn’t bother you but right now you just can’t take it so we can see how there’s a
reduced stress tolerance when somebody’s already at this stage reducing fatigue in our clients can
be accomplished in part with psychological factors including motivation or knowledge of other people
who are dealing with similar things support groups feedback about their and making sure they have
frequent successes not once a week but I want to have them keep a journal every day of something
good that happened or something positive that may indicate they’re moving forward in their
treatment goals and knowledge of an endpoint.
Where are we going with this when is the treatment
going to end I don’t want most clients don’t want to be with us forever no matter how lovable
we are do you want to feel better and be done with us so having to help them see that there
is an endpoint we’re going to accomplish this goal this month and then we can reassess 46% of
people in the US are exposed to adverse childhood experiences so like I said this is a huge area
for early intervention where we can prevent people from developing PTSD later in life how awesome
would that be instruction and skills to handle emotional dysregulation including mindfulness
vulnerability prevention and awareness emotion regulation distress tolerance and problem-solving
could be wonderful additions to health curriculums anything any skills groups you do with children
or adolescents or even adults I mean just because they’re adults doesn’t mean that they’re safe
from PTSD or that they’ve crossed any threshold where they’re too old to learn we’re never too
old to learn of those exposed to trauma education about and normalization of their heightened
emotional reactivity and susceptibility to PTSD in the future may be helpful in increasing their
motivation for their current treatment protocol whatever it is but it also just normalizes things
so they don’t feel like they’re overreacting or they don’t feel guilty for being so tired
or whatever they’re experiencing right now are there any questions I know I went through
a lot of really complicated stuff but I thought it was really interesting not only the way
our brain reacts in order to protect us but how cross-cutting a lot of this stuff
was it not just PTSD we’re talking about necessarily but a lot of this information
applies to our clients with chronic fatigue burnout and chronic stress and we can
see that those people also are at risk at higher risk of PTSD should they be exposed
to trauma and none of us is immune I mean there are tornadoes there are hurricanes
there are you know things that happen that really stink so the more we can help clients
be aware of things develop skills and tools to prevent as much harm as possible I
think the more effective we are as clinicians depending on the client and I can do some
more research on the VA website because they’re really into medications for PTSD I
know ketamine which is a horse tranquilizer has been shown to be effective in people
with PTSD and there have been some others that have kind of given me pause ketamine
is a hypnotic you know most of the drugs they’re trying out right now are really in my
opinion they’re powerful drugs but a lot of them all of them that I know of have
pretty high addictive potentials too so they make me nervous but you know when you’re
weighing the when you’re going from a harm reduction model that’s not necessarily not
necessarily such the be-all-end-all I guess that’s interesting that you use ketamine in the ER it’s definitely powerful effective stuff and like I said earlier some of the
stuff that some of my clients and some people have seen done experienced I couldn’t even
imagine and you know sometimes for them to actually survive we may need to look at some
of these more intense more powerful drugs PTSD and veteran trauma is not are not my focus
right now and yes marijuana is being experimented with or looked at used whatever however you want
to look at it for PTSD treatment with veterans there’s pretty much not a drug out there they
haven’t tried to throw at it to see well what will this do I believe they were even using
LSD experimentally for a little while too you the VA I mean if you’re interested in this
topic let me see if I could pull that down into here, we go to the National Center
for PTSD US Department of Veterans Affairs has a lot of information if you go for
professionals, it has a ton more information if you can get on get some of your SI CEUs on
demand they do have some free CEUs for PTSD here I’ve never taken any of them but what
I’ve looked at when I’ve looked at like the PowerPoints the presentations and stuff I’m
sure they’re good so if you’re you do focus a lot on PTSD and you can get on-demand CEUs
then this might be a place to get some good free ones aside from DBT are there any other
evidence-based practices for therapy that you’ve seen work best in combination with the
medications cognitive processing therapy when you’re working specifically with veterans
and there is a free course on that too and this one I have gone through
and it’s really awesome CPT dot must seed and here I’ll just put it
into that education and this is a free course oops and here’s the other one ah golly everyone and
embryo does have a lot of research effectiveness with people with PTSD too so yes I would
definitely encourage people to explore all options alrighty everybody I really
appreciate you coming today and sticking with me through this topic and I will see
you on Thursday if you have any questions please feel free to email me or you can
always also send it to support that all CEUs com either way I get it and otherwise I
will see you on Tuesday thanks a bunch 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 Doctor Snipes by subscribing at all CEUs comm slash
counselor toolbox this episode has been brought to you in part by all CEUs
com providing 24/7 multimedia continuing education and pre-certification training to
counselors therapists and nurses since 2006 used coupon code consular toolbox to get
a 20% discount on your order this monthAs found on YouTube15 Modules Of Intimate Video Training With Dr. Joe Vitale – You’re getting simple and proven steps to unlock the Awakened Millionaire Mindset: giving you a path to MORE money, …
Etc sometimes you need to
delay joint sessions until the parent or caregiver can offer the child support and sometimes that
means not even starting treatment really until the parent and caregiver parent or caregiver
can be on board now you can get started with psychoeducation emotions identification feelings
identification and stress management and coping skills you know there were not really
poking a bunch of bears so you can probably safely get started on that if it’s sometimes it’s
court-ordered and they have to start treatment by April 1st or something so there are things you can
do but you may need to delay the actual beginning of the trauma narrative until the parent is
able to be available to educate everybody on how therapy works and instill in everyone not just
the parent optima optimist that well optimism about the child’s potential for recovery you
know sometimes they’ve been dealing with this child’s acting out behaviors for so long they’re
just like you know we’ve already been to three other therapists I don’t know what’s going to
fix it or I’ve done everything I know how to do good luck so we can talk about you know a
different approach or we can talk about what they’ve done that’s worked for a short period
of time and build on those strengths to instill optimism and hope and empowerment so
initially, when we talk about psycho-education it’s important to provide accurate information
about the trauma when children are traumatized they can be confused and not completely understand
what happened they may blame themselves and they may hold on to myths because they’ve been misled
and/or deliberately given incorrect information so one of the best ways we can help is to correct
that information provides information about how often this happens and whether you know it’s okay
to do this that or the other psychoeducation clarifies inappropriate information children may
have obtained directly from the perpetrator or on their own so the perpetrator may have told them
that this is how I express love or this is how you need to be disciplined because you don’t learn
this is how I was disciplined whatever it is or they could have gotten it on their own they could
have gotten it from school from the internet or just come up with it in their little heads trying
to make sense of what happened psychoeducation also helps them identify safety issues the
difference between safe situations and dangerous situations and as we get through this I really
want you to get away from the notion that TF CBT and childhood trauma are only physical and sexual
abuse there are so many other traumas as evidenced by the adverse childhood experiences survey that
I want you to wrap your head around that and there are things they didn’t cover in the aces such as
bullying and natural disasters so we want to help children whatever the trauma is the trauma made
they feel unsafe so we want to identify safety issues if the trauma was a hurricane then we want
to talk about what hurricanes are how often they hit what to safety plan etc so every time a
the thunderstorm comes they don’t freak out and we want to use psychoeducation to provide another
way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about
the traumatic experience you know it makes sense that that was scary and makes sense that
you’re angry it makes sense that you feel this way and we can talk about why that makes
sense and why it makes you feel that way through cycle education you’re getting the child to start
talking about the specific trauma that he or she experienced in a less anxiety-provoking way by
talking in Jen wrong about the type of trauma so you’re talking about natural disasters you’re
talking about plane crashes you’re talking about domestic violence so they start learning about
it and then eventually you’re going to move down to their experience with it so like I said there
are a ton of different traumas and the ACE study even acknowledges that these are just the ten most
common ones that they heard however there are many many many different traumas and types of trauma
some of the biggest ones are physical and sexual abuse physical neglect emotional abuse
and neglect and the Aces identified mother treated violently I would say anyone in the household
treated violently it’s not just the mother’s substance misuse within the household and that
can be by the parents or by siblings household mental illness parental separation or divorce and
an incarcerated household member so those were aces but then like I said there’s also bullying
the death of a parent or sibling is extremely traumatic hurricane tornado natural disaster and
then I put the fire out separately because sometimes fire can be man-made sometimes it can be a wiring
problem but sometimes it can be Jr was playing with matches now even if jr. Accidentally started
the fire does that make it any less traumatic no it probably makes it more traumatic because then
there’s a whole sense of guilt and responsibility but it’s still a trauma that has to be dealt
with so I put a link to the adverse childhood experiences website if you want to go look more
about that but we’re going to move on psycho-education involves specific information about
the traumatic events the child has experienced not the child’s event we’re not going to go
into police records or something, we’re just going to talk about specific information about
domestic violence or whatever body awareness and sex education in cases of physical or sexual
maltreatment and there are caveats for getting parental consent and permission and all that other
stuff and Risk Reduction skills to decrease the risk of future traumatization now going back to
those other things it’s not just about physical or sexual abuse so we want to look at what was the
the risk created by you know how can you reduce your risk of being bullied how can you reduce your
risk of being traumatized in a tornado you know you can’t stop the tornado from coming
and they’re everywhere so what do you do and talk about a safety plan the same thing with fire
information needs to be tailored to fit a child’s particularly particular experiences and level
of knowledge obviously, you’re going to provide different information to a seven-year-old than
you are to a 17-year-old provide caregivers with handout materials to reinforce the information
discussed in session so this may help educate the parents about some of it but it lets them
know what you talked about and it gets us all on the literal same page you’re providing them a
handout of everything you went over with Junior and we want to encourage caregivers to discuss
this information at home reinforces accurate information about how safe or unsafe they
are and obviously, we’re going towards safe and reinforced accurate information and develop
a safety plan so they feel confident that at home they’re going to be taken care of when you
start psychoeducation you do want to get a sense of what the child already knows and you can use
a question-and-answer game format in which the child gets points for answering questions which I
love this suggestion so you can ask them if you know what is a hurricane or is a tornado and see
if they know and see if they know how much time and much-advanced warning we have for a tornado
versus a hurricane or you know whatever situation you’re talking about you see I did a lot of posts
Hurricane Katrina counseling in northern Florida so that’s one of those things that comes up for
I am talking with children about how likely is it that a category 5 hurricane is going to hit
again but encouraging them to give your aunt’s give answers and if they give the wrong answer you
know it’s great to try now you know try to coach them into a correct answer or provide them the correct
one but give them credit for at least making an effort sample questions might include what is
you know and put in the type of trauma what is bullying how often do you think bullying happens
and why does bullying happen you know those are some questions you can ask to just open a dialogue
about bullying, if this child has been a victim of bullying and is and is traumatized so cultural
considerations meet the child and family where they are by presenting information in a way which
they can relate it to their belief system and you may need to consult with their spiritual
guidance guides leaders whether it be a pastor or you know whatever to get some guidance
on how to handle certain aspects of whether it was the will of God and in the case of sexual abuse
how to handle the concept of virginity and how to handle the concept of bad things happening to bad
people and whatever else they think is coming from or their parents are instilling in them in a
belief system we want to make sure that we’re not necessarily contradicting it and going oh mom dad
and the church is wrong but we also want to help them try to integrate this in a way that can help
they have strong self-esteem so reaching out to those spiritual leaders and the family asking what
their belief system about certain things can be very helpful assess the general beliefs about
the trauma if something happened or when something happens ask the parent or the family that’s there
not necessarily the child but you want to get a sense of what the family stance is on why this
happened what it means how it’s going to impact life hence foreign henceforth and forever more
focus on the events they perceive as traumatic to the family but most especially the child if the
child’s going back to the Aces you know maybe the parents got divorced but the child doesn’t
see that as traumatic because there was domestic violence ahead of time the domestic violence was
traumatic the divorce was a relief so wherever the child is with each trauma we want to
be respectful of what they perceive is traumatic and tailor the information so the family can be
more receptive to it as supportive as possible and sometimes you need to make sure that the language
you know make sure the language is not jargony about general views of mental health and mental health
treatment should also be assessed and addressed in the psychoeducation piece not only with the child
but also with the family, if they are suspicious of it don’t understand it think that you’re just
going to magically fix Junior we want to demystify the process and talk about what is the purpose of
the assessment what is the purpose of each one of these activities and why am I doing this or why
are we doing this as a team and how can it help and then we also want to provide information to
D stigmatize and normalize mental health issues and seeking treatment some cultures are still
resistant to seeking treatment and I use the term cultures broadly because there’s
a stigma associated with it so normalizing for them how many people go to treatment how common
PTSD is or whatever the situation you’re dealing with it doesn’t mean they have to like it but at
At least it will give them a little bit of a nugget to understand that they’re not the only ones if
they are from a cultural group a minority cultural group of some sort you might want to provide
information about how common this particular issue is in their group I’ve done a lot of work
with law enforcement and emergency responders and they’re kind of their little group so
we talk about how common depression is among law enforcement and emergent emergency responders
specifically, because they face so much so many different stressors than you know Joe Schmo over
here so it D stigmatizes and normalizes a little bit now they still may not talk about it and
go well hey you know 37% of us have clinical depression no that’s probably not going to happen
but at least in the back of their mind, they can go you know what I’m looking around this room and
I can bet that at least one other person’s on antidepressants or something and feel a little
less unique and isolated in parent sessions you want to provide a rationale and overview of the
treatment model educates parents about the trauma and talks about the child’s trauma-related symptoms
so we’re going to go over what is hyper-vigilance what is the function it why people become
hypervigilant after trauma and what might it look like in a child because it presents very
differently for different children so we might want to give some ideas and say does this sound
like Johnny or does this sound like Johnny and help them understand why these behaviors may
be coming out we want to talk about how early treatment helps prevent long-term problems okay
maybe the trauma happened three years ago but still, it’s better than waiting ten more years and
you know Johnny’s still not having any Ellucian will want to talk about the importance of talking
directly about the trauma to help the children cope with their experiences and not hedging and
this will be on a case-by-case basis but the manual walks you through handling this discussion with
the parents about exactly how much detail do I go into if Johnny brings it up at home reassure
parents that children will first be taught skills to help them cope with their discomfort
and that talking about the trauma will be done slowly with a great deal of support so we’re not
just going to plop them down and go okay and tell me about the day that all this happened which
is what the child has experienced already if it was reported to law enforcement and/or the child
welfare they’ve probably had somebody sit down and say get right to the nitty-gritty at least
once or twice and it’s completely dehumanizing so we want to reassure parents that we’re not
going to do that to the child again will help the caregiver understand their role in the child’s
treatment since this modified since this model emphasizes working together as a team so I’m not
just going to be educating you it’s not going to be a parallel thing where I go in and I work with
Johnny and then I tell you what I did and then I work with Johnny I’m going to work with Johnny
and then we’re going to discuss what Johnny and I did in session and I’m going to get input from
you and we’re going to talk about how you feel about it and then I’m going to provide you with tools
so you can help Johnny outside of the session because you’re going to be with them for six-and-a-half
other days that I’m not and this can’t work if it’s just one hour once a week and we want to
elicit parent input questions and suggestions as much as possible because they’ve been living with
their kid for you know however many years so they probably have an idea about what works and what
doesn’t so we’ll start with both parents and children in their respective sessions helping
them understand what control breathing is and how it helps slow the heart rate and trigger the
wrist and digest sort of reaction in your body when your breathing slows your heart naturally
slows because the stress reaction tells your brain you’ve got to breathe fast and the heart
rates got to go fast well when you override that then you’re kind of overriding the whole system
and we’ll also talk about thought stopping and this is especially helpful if the trauma is recent
or and/or ever-present in the mind of the youth so they can say I am NOT going to talk about that right
now I’m not going to think about that right talk about distraction techniques go back to
your DBT stuff talks about improving the moment and accepts to help the child develop skills to
handle and work through when those thoughts pop up replace unthawed unwanted thoughts with
a pleasant one so talk about it in session when thoughts like that come up what would you
prefer to think about and then really get into the Nitty Gritty the five senses what do you see
smell hear taste you know help me get into that situation or that thought this teaches that
thoughts even unexpected and intrusive ones can be controlled so that gives them hope and again we’re
not exacerbating the thoughts right now we’re not bringing up their particular trauma and
having them get into detail we are just helping them deal with what’s happening normally on a
day-to-day basis so they feel like they have more control for the older kids you can have them
people log about when this technique is used what they were thinking about and how effective the
thought stopping was and then review it and help them tune it up if it’s not really effective and
give them praise for when they use it effectively relaxation training persons of Asian or Hispanic
origin tend to express stress in more somatic or physical terms so just be aware of that but that
doesn’t mean that Caucasians don’t relaxation training is good for anyone and the medical
school of South Carolina training recommended that relaxation is stress-free and
workbook by Davis Schulman and McKay so and it is still in publication when deciding how to
present relaxation techniques are creative have the child help you to integrate the elements
into the technique that makes it more relevant to them so, what are you thinking about when you
relax you know I know I like to go to the woods but maybe this kid likes to think about a video
game or play with their dog whatever it is but helps them make it relevant to them and then have
they identify other things they do to relax like drawing listening to music walking and making a
list of those things so they can refer to it when you’re teaching relaxation training especially if
you’re doing something like progressive muscular relaxation be sensitive to the child’s wishes if
they don’t wish to close their eyes or lie down which could trigger memories of the trauma we’re
not going there yet so if they feel vulnerable lying down or taking orders like that because
you can imagine how being told to lie down and close their eyes might be a trigger for certain
abuse survivors you know be cognizant of that and say you know get into a comfortable position
or how where would you like to sit while we talk about this like I said parents can often
benefit from the relaxation training as well so because they’re dealing with their issues
about the trauma but they’re also dealing with trying to figure out how to help Johnny and any
of them deal with any of Johnny’s misbehaviors or problematic behaviors then they move on to
feelings identification so it helps the therapist judge the child’s ability to articulate feelings
if you can tell me what makes you happy that’s great but if you can’t then you know we need to
work on figuring out what makes you happy you also want to help the child rate the intensity
of the emotion don’t let them stick with happy mad sad glad and afraid you know let’s talk about
different emotions and use the emotion chart with little faces on it or you can use the emotion
thermometer so is it a hot emotion or is it a cool emotion and helps the child
learn how to express feelings appropriately in different situations I mean sometimes they’re
going to be angry but it might not be appropriate to you know get up and stomp out of the room or
whatever however they communicate it so help them figure out how to articulate that so they can be
heard and supported some children have difficulty discussing or identifying their feelings so
you might try stepping back and discussing the feelings of other children or characters from
books or stories so you know think about Puff the Magic Dragon if they’ve read that you know
that dates me a little bit there but you know how did the little boy feel and talking about things
different characters and different stories where there are elements of anger and shame and loss and
all of that stuff helps children identify how they experience emotions if they seem detached
from the experience because sometimes they just they’ve shut it off it was just too overwhelming
so we want to talk about you know when you’re happy what does that feel like or when you’re
angry what happens what does your body feel like when you’re angry and they might be able
to tell you they hear their heartbeat in their ears or everything gets all fuzzy or whatever
but help them start tuning in to how they react and connecting that with an emotional word and then
after all, that’s done they can identify feelings they can identify feeling intensity now we want to
differentiate between thoughts and feelings many children describe thoughts when they’ve been
asked about a feeling so if you ask them how they feel they may say I want to run away so
you want to say okay well I hear that you want to run away so I’m wondering if you are bored and you
you’re bored and want to get away from it or if you’re scared can you tell me a little bit more
about what it means to you to want to run away during feelings identification the parent
sessions normalize what is going on with their child and help the parent understand that some
children may be seemingly in constant distress or detached from the trauma and that’s okay
we all react differently to traumas so again we’re going to share with the parents what we’re
Do let them know any specific difficulties if any juniors have encouraged the parent to praise
the child for appropriate management of difficult motions and I put in parenthesis successive
approximations because they’re not going to get it a hundred percent right every time so if they
try to effectively manage their emotions even a little bit let’s give them praise for that and
then help them figure out how to do it a little bit better the next time so instead of having a
complete meltdown maybe they got up and stomped out of the room well that’s an improvement so
then we want to talk about how to shape that behavior so it’s a more appropriate communication
if parents have difficulty identifying their own emotions provide them with examples so
continually ask them questions about how you feel when it’s a rainy day outside and how to do you
feel when somebody’s supposed to call you and they don’t how do you feel when and have about 15 or 20
examples and you can have them on a piece of paper and even give it to the parent to take home for
their homework if parents are overcome with their own emotions about the trauma validate
their feelings and explain how children need to see that their parents can handle talking
about the trauma so there the children need to see the strength and the parents which is what you’re
going to work on in parent sessions to make sure that the parents have the resolve and the skills
handle talking about this topic with junior TFC BT can be an effective intervention
for children or adolescents whose primary presenting issue is trauma-related emotional or
behavioral dysregulation TF CBT is not appropriate for clients who are actively suicidal and severely
depressed or currently abusing substances we want to make sure they’re clean
and sober as much as possible TF CBT starts with psychoeducation and then teaches stress
management and coping skills to aid in the management of distressing feelings psycho IDI
helps to clarify the inappropriate information children may have and start getting them a little
a bit more comfortable talking about the topic in general before we start going deeper and
feelings identification helps participants start effectively labeling and communicating their
feelings so they can receive the support and nurturance they need from their caregivers
and their support system 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 to all CEUs comm slash counselor toolbox this episode has been brought to you in
part by all CEUs calm providing 24/7 multimedia continuing education and pre-certification
training to counselors therapists and nurses since 2006 use coupon code consular toolbox to
get a 20% discount on your order this month.