Evaluation and treatment of PTSD and other Stress and Trauma-related Disorders - mood and social adjustment difficulties owing to traumatic work exposure or injury, other kinds of injuries or accidents, traumatic grief & loss, and other traumatizing life events*
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If long after a trauma event, you’re finding yourself re-living it with nightmares or daytime flashbacks or maybe angry outbursts or other problems with your behavior or low or difficult moods triggered by some current event (a sound or a TV show or something said or maybe a new difficult if not traumatic experience); or if you’ve been generally agitated and/or depressed or maybe socially isolated since the trauma occurred, mostly likely you’ve become stuck in a pattern of avoidance. You’ve decided that surviving what happened depends on you avoiding thinking about what happened or how it’s affected you or others and your world and avoiding circumstances or people or relationships which could end up triggering painful trauma memories or cause you to relive the severe distress you experienced in the first place, when the trauma occurred.
But what you’ve been doing to try and survive the trauma - avoiding thinking about or talking about it and hoping to escape feeling the emotions that emerge when you do - has not been working for you. And so you need a different approach, help finding a way to approach and deal with the trauma rather than avoiding it. You need to learn a more adaptive way of surviving what happened, one which leaves you remembering what happened but without reliving what happened, i.e. with a memory that does not result in negative moods and problem behaviors and other symptoms and dysfunction in your life.
To help you work toward that kind of PTSD symptom relief (post-trauma recovery or resiliency), I'll provide what I call CPT-EMDR Integrated trauma treatment: a flexible protocol which draws upon what I consider to be the best of two widely practiced and evidence-based PTSD treatments, Cognitive Processing Therapy (CPT) and Eye Movement Desensitization Reprocessing (EMDR). If you elect to include this kind of trauma care as part of your treatment with me, you can expect this treatment protocol on top of my general psychotherapy approach; the treatment methods, principles, and values which I have outlined on my GENERAL PSYCHOLOGY page.
My CPT-EMDR treatment protocol is designed to 1) help you accept the reality of the trauma event, 2) help you feel your natural feelings pertaining to the event, and 3) help you restore or discover balanced and realistic beliefs about the event, yourself, and others. To the degree that we succeed with these 3 goals, you’ll find relief from PTSD symptoms like hyperarousal (persistent ‘fight or flight’ agitation), easy startle, intrusive trauma re-experiencing, and social avoidance and/or emotional numbing.
First in preparation for CPT-EMDR, I'll have you complete the PCL5 (PTSD Symptom Severity Inventory) to establish a pre-treatment baseline. And we'll make sure we've evaluated any other history and symptom information which could be helpful in guiding your treatment. And then, I’ll review and if necessary instruct you on basic and frontline mood regulation skills (breath control, self-calming, and emotional grounding strategies) . Before we proceed with the trauma exposure, desensitization, and reprocessing work, you’ll need to feel confident that whenever you wish to do so, you’re able to shift away from any felt intolerable emotions or memories which may come up. And it will have to be understood that you’re the one in control, the one to decide when you want to make that shift whether it means aborting trauma work during a treatment session or deciding to put aside work altogether for a visit or even discontinue trauma treatment altogether.
CPT-EMDR trauma work starts with the targeting of a trauma event determined to be either the primary cause of your PTSD or if not that, maybe a more recent PTSD-aggravated event. We may decide to work first on a relatively recent event which is felt to be most emotionally ‘approachable’ even if it is understood that an earlier or ‘root-cause’ event, e.g. from childhood, is likely to be contributing significant if not the primary underlying distress. We may end up targeting multiple trauma events from different times of your life and with varying levels of distress associated with them.
After we decide which trauma to process or which to process first, we’ll proceed toward identifying the beliefs about yourself and others which have taken hold of you since the trauma even while you have consciously been trying everything you can to avoid thinking about what happened. Using the best of CPT and EMDR, we'll give you a safe and emotionally doable platform to bring to light the specific dysfunctional beliefs that are keeping you stuck re-experiencing the trauma.
Post-trauma emotional fallout and behavior changes and coping difficulties normally run their course and dissipate with time. But for that to have happened, you would have had to find a way to accept the reality of what happened and feel vs avoid feeling your emotions about it. And to the degree you were able to do that, you would have been left with the natural pain and suffering that comes with remembering trauma events or with grieving any permanent losses you suffered, e.g. the death of a loved one; but not stuck and hooked reliving the event as if it had just happened or was still happening; and not having basic positive beliefs about yourself, others, or the world shattered or further out of reach if cumulative severe past trauma had already left you with a loose hold on those kinds of beliefs.
CPT-EMDR offers a way for you to approach and reprocess the trauma, to face feeling what happened without being overwhelmed and accept what happened without feeling cynical or lost and alienated in the world; and as a part of that reprocessing, help restoring or depending on how much lifelong severe trauma you had to endure before this trauma, help learning balanced and realistic beliefs about yourself, and others and life on the planet; establish or re-establish the kinds of beliefs necessary in one form or the other if you're going to function comfortably and adaptively - beliefs pertaining to safety, trust, power or control, and self-esteem or a positive evaluation of others or the world:
Safety Beliefs Related to SELF: The belief that you can protect yourself from harm and have some control over events.
Safety Beliefs Related to OTHERS: Beliefs about the dangerousness of other people and expectations about the intent of others to cause harm, injury, or loss.
Trust Beliefs Related to SELF: The belief that you can trust or rely on your own judgments and decisions.
Trust Beliefs Related to OTHERS: Beliefs that the promises of other people or groups can be relied on with regard to future behavior.
Power and Control Beliefs Related to SELF: The belief that you can solve problems and meet challenges that you may face.
Power and Control Beliefs Related to OTHERS: Beliefs that you can control others or future events related to others (including people in power).
Esteem Beliefs Related to SELF: The belief in your own worth (that you can be and deserve to be understood, respected, and taken seriously)
Esteem Beliefs Related to OTHERS: Beliefs about the value others can have in your life (that other people can provide us something of worth, can contribute positively to our personal needs).
Intimacy Beliefs Related to SELF: The belief that you can take care of your own emotional needs (soothe and calm yourself, be alone without feeling lonely or empty).
Intimacy Beliefs Related to OTHERS: Beliefs that you are capable of making different types of emotional connections with others.
To figure out which category of belief you've become dysfunctional with, exactly what post-trauma beliefs you have keeping you stuck, I’ll have you start by producing a written Trauma Impact Statement (your choice, a statement you write on your own between visits with a form and guidelines on what is to be included in the statement or during a visit with the same form, me putting your statement in written form). Either way, putting what happened in writing is an effective means of placing events back into proper order with a beginning, middle, and end. And writing about trauma can elicit important emotions and establish the context and meaning of those emotions in ways that simply talking about the trauma cannot. It offers a good start to engaging with trauma memories without being overwhelmed by them.
One theory is that a written Trauma Impact Statement settles trauma (re-experiencing distress) by activating the speech centers of the brain as well as activating the highest-level adaptive problem-solving circuity in the brain, the prefrontal cortex or PFC. PFC activation results in a settling down of brain firing in the amygdala, also known as the reptile brain which instantly responds to trauma (to felt or feared threats to our safety or survival) with fight-or-flight or freezing-shutting down, i.e. prepares us to fight for our survival or run for our life.
And the same theory applies to EMDR. Left-right, alternating eye movements or tactile vibrations or tapping while at the same time focusing on the trauma likewise helps by simultaneity 1) inhibiting the amygdala’s ‘fight-or-flight’ adrenaline (sympathetic nervous system) arousal and 2) activating the prefrontal cortex (PFC), i.e. facilitating a cognitive perspective and the kind of emotional 'distancing’ needed to reprocess and rethink trauma (not to be confused with emotional 'blocking’ which means avoiding working through the trauma).
And so after you produce your written Trauma Impact Statement and we discuss its content and begin to tease out the key damaged and dysfunctional beliefs keeping you stuck (your most problematic 'stuck points’); as much as possible simply by talking about it trying to figure out how much of your trauma experiencing has to do with broken confidence in your safety or in trusting others or in asserting power or control, depending on your comfort level we can opt to take the discussion (processing/reprocessing) deeper or more to a 'gut level’ by adding in EMDR or some kind of bilateral, alternating sensory input (BLS).
Changing your trauma-generated beliefs, replacing them or shifting toward more adaptive cognition is done initially with some post-visit homework. I'll ask you to take one or a couple of your felt most problematic stuck points we’ve identified with the written trauma statement and EMDR and for each one, complete a ‘’Challenging Beliefs Worksheet”. This worksheet will help you challenge your stuck point(s) by for example, directing you to sort out feeling from fact or correct over-generalization or arbitrary and factually or logically unsupportable fault finding or other kinds of cognitive distortions that have you hooked on unnecessary trauma suffering. With this worksheet, you'll get well underway with the process of replacing negative trauma reexperiencing-fueling cognition with the kind of positive cognition necessary for you move past the recurring and overwhelming reliving of the trauma.
Your first visit back after you complete one or more of these worksheets, I'll have you rate from <10 to >90% the degree to which you believe both the stuck point or negative cognition you've identified and also the degree to which you believe the alternative positive cognition you've targeted as what you'd rather believe, what you know would help relieve you of your PTSD symptoms, to the degree you can and do actually believe it. And along with these ratings, we'll get an update on the severity of your PTSD symptoms by having you complete another PCL5 (repeat the baseline inventory I had you complete as part of your initial evaluation for treatment).
And then, we'll deepen the cognitive restructuring and other trauma reprocessing work by reintroducing the EMDR or other kinds of BLS. CPT-EMDR integration at this stage of treatment results in a more thorough uncovering and restructuring of your trauma experience; better assures that we'll sort through all the themes or storylines with which you’re suffering and means that the PFC (prefrontal cortex)-mediated 'big picture’ and rational decisions you arrive at will better take root at the 'gut level’, i.e that the cortical cognitive-level reprocessing will simultaneously be rooted in the amygdala, in the subcortical ‘reptilian’ fight-flight or emotional approach-avoidance part of the brain.
We'll end up repeating this process as much as it proves to be helpful or as long as your PTSDsymptoms continue to lighten and/or adaptive and normal memories about the trauma event or beliefs about yourself, others, or the world continue to strengthen. And at the end of treatment, I'll ask you to complete a final PCL5 and do final strength of belief ratings on all the positive cognition (specific, coping thoughts) we've targeted and worked toward, as part of your treatment.