Psychiatry & Psychotherapy Podcast - How to Treat Emotional Trauma

Episode Date: August 23, 2018

What is trauma? Emotional trauma comes from stress that is overwhelms a person's neurological system. Some stress can be good and formative, or it can be bad and get stuck in the brain, causing someone deep emotional pain. Think of climbing Mount Everest. Some people choose to do that, and it's easily one of the most stressful situations you can put yourself in on purpose. That's good stress if you have trained for years and are ready for it. If someone forced you to climb Mount Everest, it would register in the brain as a trauma. Trauma is too big for the mind, brain, and nervous system to assimilate. It's a memory, or experience, that gets stuck because the person believed it would result in their death, or at least serious injury. The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct. People commonly demonstrate symptoms of trauma when they've: Experienced a sexual violation Seen violence Experienced violence or abuse Been neglected—experienced the absence of something that they should have had. Been in near death experiences like car accidents or war People who have PTSD, or post traumatic stress disorder, have experienced a soul-level of brokenness, and even talking about the event, or having a memory of it, can bring it back with the same force that occured in the actual accident. They often have recurring nightmares, or repetitive symptoms that continue long after the event. Typical PTSD symptoms alternate between chronic shut down and fight and flight Fight and flight symptoms are: Sweating, nightmares, flashbacks, anger, rage, panic, hypervigilance, tense muscles, painful knotted gut Shut down symptoms are: Dissociation, freezing, emotional detachment, voice trembling, difficulty getting words out, numbness, apathy, fear, helplessness, dizzy, empty, nausea Moments in connection mode look like: curiosity, exploration, relaxed and full breathing, feeling grounded, true smiles By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Okay, so today I'm here with Randy Stennett. He is a sci-D. a PhD level clinical psychologist, and he oversees a bunch of trainees in clinical psychology.

What are you doing right now at the SAC Norden Center? Sure. So I'm one of the co-managers of the behavioral health department, so overseeing our behavioral health clinicians' activities and our psychiatry residents and just keeping a lot of that stuff going over at the SAC health system. So this is an FQHC, which is basically kind of a high risk, indigent population, people who don't have insurance. The government provides wraparound dollars to Medicare, Medi-Cal, which allows these patients to be seen. And so,

you know, lots of trauma. A lot of trauma. A lot of trauma. You just want to expect that trauma will be there in front of you in some form or fashion. So today we are going to be going through talking about PTSD, talking about trauma, the results of trauma. Dr. Stennett has a lot of experience. We have a couple of patients together who have been through quite a bit of trauma. And so we've collaborated and really excited to have you on. Thank you. It's my pleasure.

Thanks for the invitation. And I've actually had them on earlier. We were just talking about sort of the past to become a therapist. earlier on in the podcast. And so this is our second episode together. So today we're really going to go into talking about trauma, some of the DSM criteria. We'll talk about some of the stuff that you need to know

if you're a student in this field. And we'll also talk about some of the neurobiological correlates and the treatment. But we're going to try to make it very practical. So trying to help both the person who might have experienced, trauma to understand what's going on and why they're experiencing what they're experiencing, but also the clinician, the therapist, the psychiatrist, the person in training to kind of give

them a framework for understanding trauma and trauma-based diseases. Sounds good. So I think first we should define what is trauma. So how would you define it? So a trauma is something that is too big, I think, for the mind. the brain nervous system to really assimilate into memory systems. It's too big and it gets stuck in a sense, a memory and experience. And one of the things that makes an experience get stuck oftentimes is that it was something

that the person felt would result in their death or serious injury. And the brain has several mechanisms to keep something stuck so that, the person will remember it in the hopes that they'll avoid it in the future. And this has many aspects with brain, you know, neurophysiology and in the nervous system that make for quite a complex experience. Yeah, I like that. It's too big. The stress was too much.

So we know that stresses can be a good thing, right? If you have a stress that's of a certain amount and you're able to recover, and you're able to adapt, you're able to get stronger. But in general, a trauma, because it is a near-death experience, because there is such a large degree of violation, it can overwhelm the system, the way that it's sort of, we organize thoughts. Well, it's like the person, there's some kind of a deep primordial fear of the disintegration of the psyche or the self or the body that results in,

in what we call post-traumatic stress or chronic, chronic PTSD. So some examples of this might be, you know, sexual violation, right? Because there's that risk of death that comes with that. There's direct and indirect domestic violence. Yes. So actually watching domestic violence can be a traumatic experience. Absolutely, absolutely. I have a patient who talks about how just the fact that,

that she has gone through what she has, there's a sense at which she feels irreparably broken. And that sense of brokenness is, you know, it's like a soul level kind of experience, a sense of oneself. Yeah. That can result when, you know, experiences that we end up resulting in the diagnosis

what we call PTSD are so chronic and so deep. Yeah. Um, neglect. Definitely. Neglect. So neglect is the, is the absence of something that you should have had. And I have a lot of patients who, when they described their childhood, they felt like a ghost. Yes.

They felt like they were never seen, never heard. And often the only attention they got was, was traumatic attention, where, you know, abuse, physical or sexual. Absolutely. It is traumatic to not be seen, especially in one's attachment, formative attachment years. And we call family of origin to not be seen is extremely painful emotionally, and that is traumatic. I've had patients with near-death experiences, whether it's a car accident. And with a car accident, you know, there's both the damage, the physical damage, but often the part that continues is the psychological damage of that a couple moments before the car accident where the

person felt like they were going to die. Yes, yes, absolutely. Yeah, I'm working with a few patients right now where, you know, it's that pivotal moment of I'm going to die where time kind of slows down and the visual memory too of what's happening kind of crystallizes and that gets replayed often as part of the reexperiencing symptoms, which we'll talk about. And, And in a sense, they feel like they're going to die repeatedly whenever that visual memory and all of that gets evoked. It comes back with the same force of the actual experience. When the picture comes back, it's not just the picture, it's the actual fear of I'm going to die. Yeah.

Which is the dread, the panic. Yeah. So in a sense, PTSD or trauma in a sense is the past continually recycled. and being made present. Yeah. Yeah. So a little story I'll tell, which I heard from Bessel van der Kolk, which he wrote a book called The Body Keeps the score,

which I think is actually the number one book on psychology right now on Amazon. Yeah, should be required reading for anyone interested in treating and working with post-traudic sense. I'll link that in the blog that goes with this. Yeah. But basically, Pavlov, you know, he did these experiments on dogs in which they showed classical conditioning, like you ring a bell, you show the dogs, you have the dog eat,

and the bell conditions the dog to salivate. But another story of his was his lab was flooded with ice cold water. And for a couple days, his dogs in these cages had the cages slightly full of this ice water. And what he described was that the way they moved about the world after this incident fundamentally changed, the dogs, being stuck in the cages, being stuck in this ice cold water for a couple days. And also they seem to lose their instinct or purpose. And so there's something about trauma that changes the way that we move. Yes, yes. the way that we move.

And if you look further at like 9-11 or New Orleans, 9-11, people were moving after this incident. People were running away from the incident. And in New Orleans, when after the floods, they got airlifted out and put in gyms. And they weren't allowed to return home because of fears of fungus and that kind of stuff, you know, in their houses.

And they were stuck in these, these gyms, you know, for months, not able to do anything. And the rate of PTSD in New Orleans was actually quite a bit higher. It was like 33%. Whereas in 9-11, it was 16%. Yes. Okay, so this makes a lot of sense when we realize that, and going back to Levine's work, about somatic-based approaches to reprocessing trauma in a sense,

is that the body is designed to move away from danger. But if the body can't move, if the body is stuck, which is like a feature that's so ubiquitous with trauma, interpersonal violence and trauma is like, you could not move. And that's what the body wants to do. So the energy gets stuck. Yeah.

And Peter Levine, just for those who you don't know, is a, he's one of the, probably one of the two top somatic sort of therapists, not a researcher per se, but he's more of a practical clinician. And so he'll speak at conferences like the evolution of psychotherapy. And there's a group that study his approaches is called somatic experiencing. And he kind of integrates the polyvagal theory and kind of got me interested in this stuff along with some of the other guys we'll talk about. So one of of the interesting sort of approaches that I have to thinking about trauma is through the stillface experiment. And I'll link the video in my blog and a previous article I've written on this.

But the still face experiment really shows what it shows is a mother interacting with an infant and the mother's playing with the infant. And then the mother is told to develop a still face. and so the mother's still face doesn't react to any of the infant's ploys for reconnection. So there's kind of three phases that you can see when you watch this. The first phase is the child trying to engage the mother in playful ways. So the child is pointing because usually when the child points to something, mother looks and mother points. The child reaches for the mother's face to try to touch the mother.

the child does some funny little noises and tries to be cute. You know, these are like kind of playful ways of re-engaging connection. And then the second thing you notice is that the child starts to do things that are more more kind of in like a fight-and-flight state. The child bites himself, the child screeches, the child gets angry, and you can see the angry expression. And all of all the while the mother is still with, this still face. And then the third thing is the child loses bodily composure. So the arch

back, the kind of the body posture fundamentally stoopes and is contorted. And the child looks away. And so this is sort of that third phase of what happens when the mother has that still face. And this is kind of more of that shut down or dissociative place that I've talked about in in the previous one on the polyvacal theory. And what I think is really interesting about this is that the moment that the mother stops the still face and reconnects, the infant smiles and coos and they kind of reconnect and they start mirroring each other again. But it's actually really distressing to watch.

It's really distressing to watch this video. And it kind of shows the progression that someone goes through, especially interpersonally Interpersonally how they try to engage and connect and towards the end you can see the sort of the increased thwartedness that sort of dissociative experience and when the child goes back to this room

months later the cortisol increases Yes yes The child does not want to go back to this room Yeah but you can imagine a child who's going through their early couple months of life with a mother that is always disconnected. A mother maybe that's on meth and alcohol, you're checked out, or, you know,

really poor child care. And that kind of lack of connection, right, is kind of a deeper trauma. Yes. Well, I think that this experiment really, highlights the variation within trauma, right? So we have attachment-based trauma. What ultimately with later traumas in life, we can term like complex PTSD versus like the single traumas, let's say, of like

a motor vehicle accident or an attack or something. Trauma is ubiquitous. And I think that that early attachment trauma often sets people up for the later traumas in life, like the car accidents and things like that, the near-death types of things, to be so much more impactful and a much more bigger assault on the nervous system

and on the psychological functioning of the person. Yeah, one thing I heard from a resident was first-year-resident. They were saying, maybe we shouldn't connect very much with inpatient patients because we don't want them to love coming inpatient. Yeah. And Dr. Tar, who's my mentor, he's like a 90-year, almost 90-psychoanalyst who works in Pasadena, he was there.

And he was like, no, absolutely not. Like, you always want to try to connect. Yeah, yeah, yeah. We don't want to be the still face to our patients ever. Absolutely. Absolutely. And we don't want to be the fight and flight state either, which is more of the, you know, getting defensive or being kind of brash. We want to, we want to be in a more connecting state. Yeah. Yeah. Which is in a more attuned state, which is, you know, mirroring their emotions to some degree and to feel what they're feeling. Indeed. Well, and the fear of that, we don't want them to associate warmth and connection with. the inpatient experience. It's like, on the one hand, it can appreciate that because the concern is that would be reinforcing for all of the things that brought them into the hospital, you know, for that to happen again. But it also leaves out the point about really opening up the dialogue with

the patient about that very thing and say, hey, you know, you're getting warmth and connection here, but how can we help you maybe achieve that in the more natural environment of your life so that you don't have to have that this be the only place for that to come into the hospital yeah and i think when patients experience a really bad inpatient experience and i think it's more common than i would like to admit that happens because of the nature of how fast-paced it is and yeah just how stretched resources are at this point um when they have that bad experience and then they come to me in an outpatient setting they never continue their medications. Further, they may not even want to see a psychiatrist ever again.

And it might be even harder for them to get into therapy. When they have a really good experience and they feel very connected to a resident or an intending, they often are willing to take the medications and seek more treatment, go to therapy, go to a partial hospitalization program. And from there, they can continue their journey. you know and continue that sort of work which is hard work it's very hard work it's very hard work because people who are traumatized early on as infants and children didn't by default oftentimes learn and acquire the self-regulation skills that they need to be you know a functioning and and achieving person in the

world that's a lot of work you know to deal with as an adult. Yeah. Yeah. Okay, so I will link the Stillface experiment, so you can read more about that if you're curious. Next, I want to talk about trauma's progression. So when we think about trauma's progression, we think about, you know, the patient first

may be getting aroused. So something is dangerous. Something is going on. I need to be alert. I need to focus in. I need so it's the amygdala kind of turns up the fear centers and they're kind of a little bit hypervigilant. They're looking for danger. Okay.

And then they see the danger and maybe the response is to run away. And that's a very normal response to danger. You could think of if they're not able to run away, then maybe they fight. And they try to fight. And if the fight, if the escape is unsuccessful, then they may be moving into more of what I would consider a traumatic state, like a shutdown state. So that goes back to the dog's observation in Pavlov's lab. They couldn't move. They couldn't move.

They were stuck. It also goes back to there's been studies on rats and what elicits chronic stress. and it's being restrained in a cage for at least six hours a day, for about 30 days, the hippocampus actually starts to be damaged, like the brain actually starts to be damaged. So it's this experience of fear, of helplessness, of being scared stiff. In some of my patients, one of the most traumatic experiences that they recall that still lingers around in the nervous system is memories of being held down and uneasual. able to escape. There's fewer things, I think, more disorganizing than that when it comes to trauma.

Yeah. Yeah. And I think the therapy correlate of how to not do this is to not force your patients to do anything. Absolutely. And sometimes when I have a patient that's very paranoid and is fearful of being stuck, I'll say, you know, I want you to know that at any point you can just walk out of this room. Absolutely. Yeah, and it can be a little bit more difficult if the patient's suicidal and they want to kill themselves and they're impatient. You're not going to let them necessarily walk out the door. But I may say to the patient, you know, my goal is to not keep you here indefinitely. Yeah, yeah.

I'm going to keep you here until we can develop a plan for your safety to keep you, you know, so that you don't kill yourself and create a permanent solution to something that potentially is only temporary. Yes, and can be changed and fixed in a certain way. Yeah, I mean, you always want to be judicious on kind of what interventions you use for which patients with which kind of, you know, reasons for treatment. But, but yeah, I mean, it's like, and I've often told patients that I'm working with is that you are in the driver's seat here. And I will never force or compel you or pressure you to do something that you don't feel ready, which doesn't mean you feel totally comfortable, you know, in engaging in the treatment of these very painful things that are kind of stuck in your memory. it's going to be uncomfortable, but you will never be forced to do it. And I think that's an important point.

I tell patients sometimes to write out, I do not want this to be another perpetration. Yeah. Yeah. And I think, I can only think of like one experience where I actually had to let a patient go based on them wanting to command the ship, so to speak. Unfortunately, I just couldn't be complicit

in her. continuing medications which could put her at very high risk of death. You know, if you're on multiple antibiotics, you can have C. diff, you can have clostridium difficile and infection. So. Well, I think that also speaks to the fact that as psychotherapist, we have to be on the side of truth and reality. And it's the kindest thing we can do for a patient is to, you know, perhaps not, not collude with something like that. Yeah.

Yeah. But in general, I think I try to give the patient choice on, you know, do they want to take this medication? I'm not going to force you to do something. Now, if I'm providing treatment for someone, like in the day treatment hospital here, and they don't want to get off of drugs and alcohol, then I, you know, I may not allow them to continue in my treatment with me. But that, but those are the boundaries that would allow them to have. a successful outcome. So I try to set up, I try to explain it in such a way like, look, in my mind, for you to have a successful outcome, you need to do these things. You're a free agent. Like you can choose to listen or not to listen to what I think would be what would be the most helpful for you. Okay. So that brings up an important kind of bigger topic of exploration with trauma focused treatment, which is boundaries. And not simply just the more objective. objective legal boundaries that we have to be conscious of, right, with engaging in psychotherapy and medical treatment. But it's like, you know, holding the boundaries of the treatment frame.

Right. That is, if you think about individuals who've come through tremendous attachment-related trauma, where there were no appropriate boundaries within the relationships in their early formative years, in a sense they're crying out for that structure. You know, the emotion regulation function of healthy attachment and also with optimal frustration, you know, in infancy and in childhood, make for the ability to create a frame and a boundary within the self, self-regulation. If patients didn't have that early on, they may try to push those limits of the boundaries and their, be. But if we hold those for that frame strong, at the end they become very grateful. It's like I needed you to be strong for me. Yeah. Yeah. And I think, um, especially with a couple of my patients who have been sexually abused. Exactly. You know, my boundary of not touching patients.

Exactly. So, you know, I don't shake hands. I don't give hugs. You know, maybe on the very last time I see them, I'll give them a short hug. But, you know, in general, I, I tell patients, I, I, I, I tell patients, I really just don't touch patients and that's my boundary and I've been, you know, I have a history of that. And it can be very scary to be in, you know, a close relationship with a male if you are someone who's been abused by males. And I think that knowing that boundary is there, although sometimes they want to give you a hug, they want to, you know, shake your hand. It's like, it's almost something that becomes safe. It's a safety of sorts.

I don't know if you have thoughts on that. Yeah, like in a sense, they know deep down that you're going to be safe with them. You're not going to harm them. You're not going to be a perpetrator. And so part of, I think, maybe the interest to reach out to connect with the therapist is what would it be like to have that kind of a, you know, maybe handshake or even that side hug? knowing that it would be experienced in a way that's not going to be traumatizing for me.

Now, at the same time, it's very important. We always have to keep in mind the very real reality of transference. And what the behavioral, let's say, action of that kind of contact might evoke in that person in terms of the erotic transference or something where, you know, they may have responded appropriately, but inside it may set off, you know, some kind of fear or emotions. They don't know how to process. And while you're, you know, you want to definitely explore that in the treatment with the patient if they have those kinds of reactions and everything kind of above ground, above water, um, in the sunlight, in the dialogue with the

patient. But, um, but, um, but yeah, I mean, well, I think whatever the therapist decides, they have to be clear on why they want to hold a particular boundary and for what reason. You said sexualized transference. Can you define that for me? Well, I think that, you know, when emotions or impulses of, let's say, sexual attraction or what we call like erotic kind of transference, start to be experienced on the side of the patient toward the therapist. you know, sexuality is extremely something almost very fragile and the emotions that come with that. And there's many reasons why, let's say, a patient might have that kind of transference or those kinds of feelings toward a therapist,

particularly if they've been traumatized early on. It's like, here's somebody who's safe, here's somebody who, especially if it's, you know, opposite gender, all can occur with same gender, but opposite gender. You know, here's somebody who's safe. Here's somebody who's, you know, sense of strong. Here's somebody who has a kind of a projection, shall we say, of somebody who can can really handle these difficult things that I'm bringing, almost like a caregiver.

Yeah. You know, and so that can evoke a lot of emotions. And underneath often the sexualized feelings can be a sense of, I really want to connect with this therapist. I want to have a sense of safety in that connection. But it gets all sometimes confused, you know, with sexualized feelings. Yeah, it can be, that can be tricky, tricky work. Thanks, thanks for that.

Yeah. It may have been an incomplete, you know, explanation, but I think experientially in treatment, you know, the too often commingle because it's very difficult to sort these things out internally. And I think a good therapist will allow for these things to be put to words, but not acted upon. Absolutely. And I think that that can be, it can be distressing for the patient to hold that without putting it to words. Yeah.

And they're relying on the therapist to be the one who takes the lead on putting this into words. words. Okay. Let's keep going. Yeah. So a little bit of history. Pierre Jeannet, I think I'm saying that right, wrote a lot about hysteria and dissociation early on.

And even before Sigmund Freud was writing about it, and then Sigmund Freud came around. And in one article, he linked hysteria, which is kind of was a cluster of. of somatic experiences, affect regulation, emotion regulation issues, and PTSD type of symptoms with child abuse and sexual abuse. And after he wrote this article and presented it, he had such a strong backlash from the intellectual community that he kind of backtracked a little bit.

Yes, yes, yeah. It's interesting there. I read some of the writings in the books, on folks who went through and chronicled that time period for Freud and basically said that he made a shift once the, you know, he was treating a lot of the aristocracy of that time period in Vienna. And a lot of the, of his female patients were the daughters and of a lot of these, you know, upper echelon, upper class people, you know, of their society who, you know, we're basically talking about sexual abuse experiences.

And at some point he kind of realized, I can't come forward with this, kind of big picture and deal with it directly. And so then he kind of shifted in his theorizing to blame the victim approach to his psychosexual theories of psychopathology, where it's, it's impulses for sexualized impulses toward the father or toward the parent that are breaking into awareness. Yeah. Yeah. And so that was a little bit of a backtrack, I think.

Yeah. Hulene Jackson, 1835 to 1911, he was quoted saying, the higher nervous system arrangements inhibit or control the lower. And thus, when the higher are suddenly rendered functionless, the lower rise in activity. Yeah, yeah. Say that in a different way. Well, I think that, so I had one of my mentors,

which I mentioned in my first episode with David here, he always talked about something very important because he was a neuropsychologist. And so he said, if you don't understand how the brain works and how the brain in the nervous system are organized, you're not going to be a good therapist. And I think what he's really getting at is unless you can appreciate kind of the hierarchy of how brain, the nervous system, neuroanatomy, neurophysiology, different parts of the brain, really have primacy. You know, emotion is more primal and has primacy over, you know, frontal lobe, prefrontal, executive functioning.

If you don't understand that and you don't understand how to work with emotion, you're not going to be an effective therapist. And so when the limbic system, which is the part of the brain that kind of registers trauma and registers all of that is activated, it's going to be very, very difficult for a person to talk themselves out of that traumatic experience in the moment. when all those feelings and all those memories rush in from whatever traumatic things that happened. And so you have to understand how to work with those lower level, let's say, factors and aspects of the nervous system when it comes to trauma-focused therapy. Yeah, you have to, first of all, you have to access it. So for someone to actually talk about their trauma, their voice is going to change. Their voice will change.

They are going to feel things in their body. They're going to start sweating or they're going to start feeling to some degree what they felt in that traumatic moment. Okay, so we have to. So this is an important point here because we have to understand something that trauma-based memory, we call it emotional-based memory, is not simply a kind of memory that's like, what did you have for breakfast this morning? that's more, let's say, you know, like, it's episodic memory, but it's not what we're talking about here. Trauma-based memory has many components to it. It has, you know, the sensory aspect to the memory, so the visual component, what did you see, what comes before the movie screen of your mind when that memory is activated?

And then the emotion that's activated. and then the bodily sensation, which is all facilitated by the nervous system. And then what do you believe about yourself in relation to this? But then also another component is what was the self-experience like? So I see many patients when those trauma memories begin to be activated, which they have to be if you're going to do trauma-focused work, all of a sudden they start sounding and presenting and looking quite a bit younger. younger, right?

I see it sometimes it's like the voice changes to the age that the trauma occurred. Exactly, exactly, exactly. Some people, when they talk, their voice is stuck in the age. And one way of thinking about this is when you're really young, I'll do it just to, you talk from the front of your mouth. Yep. And the younger you are, the further in front of your mouth, you talk. Interesting.

And then as you get older, it goes back. to the back of your mouth. So you talk from the back of your mouth. And then you start talking from more of your throat and then deeper into your chest. More embodied in a sense. Yeah. So when someone is in a memory,

there is a, there's representations in the brain for what parts of the body were present during that. And so I think that's where that, voice change occurs. Yes, absolutely. The other thing about that is when they're talking about something traumatic, the cranial nerves are largely innervated by the nucleus ambiguous, which is that sort of myelinated, parasympathetic connection mode place. And so when someone moves

out of that connection mode, the normal prosody of what they say changes and the intonations. And they become a little bit more staccato if they're in fight or flight or it's harder to get the words out in more of the shutdown. Exactly. That's the dorsal vagal. The dorsal vagal. I like to think of it as d stands for danger. Okay.

That's how I remember that. That's how you're normal. And V for victory. Okay. So ventral's in that, the ventral vagus nerve for those. experiences or the facilitation of connection and for calm and for being in a sense in a sense of safety. Yeah.

Yeah. Yeah. So some writers and therapists have talked about that in what we were just referring to as an ego state. So the ego state of the person that kind of got frozen or stuck that is accessible when the trauma memories are accessed. It's like, what was my self-execis? experience and the age and the way in which that part thinks of themselves and experiences

themselves. Yeah. Okay. And that goes into another whole discussion on dissociation and how, you know, part, you know, the use of the word part does not necessarily mean full-blown dissociation. But I'd like to think of it more as how do you experience yourself in relation to this memory? Okay. Okay. Yeah. I think one thing that occurs is to access a traumatic memory, the connection you feel with your therapist or the person you're talking to about is very important. Absolutely. And that connection in and of itself is part of the therapeutic success in my mind.

Yes. Yes. Okay. So this is a very important point here because in all of the evidence, based trauma-focused therapies that I'm aware of, and I'm trained in practice EMDR, which is eye movement desensitization and reprocessing, is there's a lot of time that absolutely must be spent up front in gendering that, in a sense, that secure attachment and that sense of safety, which can only be learned through experience with the patient being able to have a bodily based sense that it's safe to be with this therapist. You know it, they know it intellectually, but they have to have a felt sense of it in the body. And the therapist has to be active in engendering that too, as well as teaching the patient various techniques for self-regulation,

whether that's relaxation, or there are the myriad other grounding skills that we teach patients. And we have to practice them, you know, with them. But, But absolutely there must be a sense of safety. Yeah, I actually, when I have patients that I refer out to do trauma work, and they come back, because I'm playing in this case the more of the role of the psychiatrist, the person that's helping guide the path, right? Maybe not doing the majority of the work, but helping sort of guide the path towards the successful outcome. I'll ask them, how do you? experience the therapist. Very important question. And, you know, I work with probably about 20 or 30

therapists in my community that I've worked with. And what I've found is that some work really well with some and some don't work well with some. And that's okay. Yes. And that's okay. So I tell the patient, if it's not working out well, can they, do they feel safe enough telling the therapist why it's not working out well? So I always try to push the patient to express what is the conflict that they're experiencing? And most of the therapists that I work with will be, are big enough, and I mean big enough, as in like, you know, they've done their own work,

they know how to receive feedback well. Yes. To not get defensive. Yes. And not getting defensive is so important. And just listening to the feedback of the patient and learning and growing in that process and also working through, you know, miscommunications and maybe, you know, there's part of your

approach which hasn't been working, right? So you can adjust a little bit. So I try to always steer the patient back towards expressing the discomfort or the issue or what the person said and trying to give that feedback. And if, and what happens is the therapist, 90% of the time, navigates it well. And now the client is reconnected. Yeah. Okay, so let's park there for a moment because so many patients who were traumatized

repeatedly in their early families of origin relationships were constantly invalidated. They had a concern. They had a protest. They had, you know, they wanted to express something that wasn't going on. And they were not received. And they, in fact, were told,

you're wrong. Yeah. And I'm the parent and you just have to shut up or you have to just deal with it. And they weren't allowed to express, hey, this is not working for me. And when they did try, they were met with shut down, stonewall, no power, no influence. Or abuse. Or then abuse, right. So then to have the experience where they can come to a therapist and say, you know, when this last few sessions have not been going well

for me or when you said this, that didn't sit well for me. If a therapist is defensive, it recapitulates the trauma. Absolutely. And then there's an assimilation on the part of the patients that, see, I don't have a right to my own voice, my own concerns. But if a therapist is strong enough to not be defensive, to manage their own reactions in the service of the patient's well-being, to say, I hear you, I receive you, yes, let's, let's be. Yes, let's be. You're not, me look at that. I could have not been managing that well. Yeah, I was having an off or yeah, I wasn't paying attention. Boy, that can be validating. I think the first thing to lead with is to validate the emotion and the experience of the patient. So if they're angry at you, you know,

I don't jump to defending, well, I didn't mean that or that's not what I said. You're not remembering that incorrectly. Don't go there. The first thing to do is, I hear you're distressed. Yes. Thank you for bringing this up. Because, I had no idea. Yeah. Or I sens something was a little bit off when we left last time. Tell me more.

Yeah. You know, I would like to hear about this. So you're almost like you're meeting them where they're expecting abuse. They're expecting with emotional withdrawal. Yeah. They're expecting that you're going to fire them. Yeah, yeah. And confirm all the terrible things they think and believe about themselves deep down.

Yeah. And instead, you're like, thank you for sharing this. And it's like, it's like a breath of fresh air. Yeah. And it almost like disproves by doing that the very things that they've started to believe. Absolutely. Further, it allows them to be more honest in the future. Yeah, yeah.

Which is so imperative for this kind of work. Yeah. And then you drop that down after you've had that interchange of thank you so much and you validate the emotion. And you validate also the valid, as Marshall Inahan says, you validate the valid, which is their perception of what happened. It means their perception. And so, and then you explore. And then you go, okay, now what was that like for you to hear me receive and validate what you just shared?

I didn't abuse you. I didn't. What was that like right now? How does that feel in this moment? And you work that down to those somatic levels and you help the patient assimilate. So that brings in the left hemisphere, if we put it in those terms. Right. to consciously put words to what was that experience like

to not be met with abuse, but instead to be met with reception. And by the way, this helps in receiving feedback in any context. I recently was coaching a resident who was seeing me about how to respond to negative feedback from a boss. And in this context, I actually believe that the boss was giving,

incorrect feedback. And so did the resident. Now, I don't know all the details. I wasn't there. But it sounded like it was kind of the boss, the attending physician was trying to justify themselves and defend themselves and wasn't open to receiving feedback. And so it was kind of giving the feedback out of a defensive place.

And so I was coaching the resident. Well, like, before you kind of counterattack, or don't counterattack. Yeah. Don't feel like you need to justify yourself. First of all, say thank you for sharing. I'm glad you shared. I'm glad you're not just holding this.

And I'm glad we can have open communication about this. Help me understand what happened here that I can learn from. And I hear you're frustrated. You know, I'm glad you're expressing this. So you do all these things that we're talking about. Yes, yes, yes. And then you remove an adversarial type of approach. Yeah.

And instead one of agreement in a sense, not of the content so much, but of the dialogue. The dialogue. The connection. Right. And then from there, you can take that information and you can go to your mentors. You know, and maybe take away the person's name and say, hey, is this true about me? Do I sometimes respond to patients in this way? Do I, how much of this is true or not true?

So you can take that information. And I think it's actually really helpful to tell the person who's giving you the feedback and say, hey, look, this is new information for me. Or I want to process this a little bit. I'm going to try to work on this. And I'd like this to be a continual dialogue. And tell me if I'm doing better in this or how I can improve in particular. That's the person who's bound to improve. And it also engenders a sense of respect.

You respect people who are not defensive. Right. Yeah, because they're not protecting their ego. Yeah. And I think that the people who have a really, really hard time with accepting feedback are people who are always, who feel this need to defend themselves. And I think it's very normal. Yeah, yeah.

I actually think it's like it's not normal to respond in the way that we're talking about right now. Indeed, indeed, indeed. Well, I think I've heard it said, which I really agree with, is that, whether it's personal growth or spiritual growth or any of that, it's about transcending that part of you that seems to be, you know, that biological part, let's say, that's like to protect. Right, yeah. It's to transcend what's supposed to, in quotes, come natural.

You can't grow without embracing the discomfort. So you get some of the feedback and then you can take it and sort of bounce it off other people you trust. Indeed. A good friend will not just sort of join your side every time, right? Yeah, yeah, yeah, yeah. A good friend will kind of speak some truth in your life. Absolutely.

And not be afraid of you rejecting them. Because if you're really close, then, you know, you'll still be connected, even with the difference. Yeah. Yeah. And why are we emphasizing this so much when we're talking about PTSD? Well, we have to emphasize it because the patient who struggles with post-traumatic stress is always going to be in a sense of protecting themselves. And protecting themselves from you, especially in the beginning.

They don't know you. And particularly depending on the kind of trauma they've experienced, it's like, you know, all those abusers often can get superimposed upon the therapist. and it's very important that the patient has a different experience with you, that you are not the expected, that superimposition of all those past people, that you're different. And you have to wipe away, in a sense, those projections so that the patient can meet you afresh. And I'll also say, I hope that I'm not just giving. you sort of intellectual, like, it's almost as if you can take the advice intellectually and not

believe it. But I hope I'm, I think most of all, I'd like to convince a person, a student of this that it's a way of being. It's a way of being. And it's a growth that has to occur in you to be able to receive feedback from people and to honor their experience. as valid. Absolutely. So if we take this back to the patient, this is why with the trauma patient, it's so important that the work doesn't just simply stay at the intellectual level. This is why traditional CBT doesn't work for reprocessing trauma because that's left hemispheric belief systems. This is about a lived experience. So you have to constantly bring it back to what does that feel like in the body right now,

especially in moments of disconformation. So the patient brings a concern, and not only are you not defensive, but you receive them, and you validate their emotion, and you validate their thinking, and you validate their perception in a sense that, yes,

you have a right to bring your perception here, even if it's a criticism of something I may have said or done. Then the patient has a new experience where they're met with respect, and compassion and validity. And then you bring it back to, now what does that feel like right now with me here? And then you have to be conscious to whenever the opportunity arises,

to engender a felt sense of that difference because it's going to feel good. Yeah. And that's what the patient's ultimately after in coming to therapy. I need to feel good, all right? Let's see how we can help you feel good in our therapeutic relationship. in these pivotal moments of validating your voice.

Right. And if someone can go into a traumatic memory and have their voice validated with you, that becomes a corrective emotional experience and a corrective emotional relationship where you are now inserting into their memory yes. A positive connection.

Another option of being. A positive connection with a person that cares about them, that is listening to them, that is for them. And that changes the very nature of that traumatic experience. Absolutely. And since our work as therapist has to be one of fostering assimilation of these experiences, so you always have to bring it back. How do you experience that right now, that sense of feeling good here with me? How do you experience that in the body? Where in the body do you experience that right now? You know, where the check? The or in the shoulders or, you know, where, where do you feel that? Well, I feel that kind of a warmth

in my chest right now as you share, as you have received me and you've, you know, respected me. All right, so just stay for a moment with that experience and that, you know, that warmth in your chest, you know, what is that like? Yeah, it kind of, it kind of reemphasizes or can sort of bring in the left brain. Yes, yes. The verbal brain, the analytical brain into the more experiencing, the more, you know, emotional, bodily parts of themselves. Yes.

So this point about, again, going back to understanding how the brain's organized, very important with doing trauma-focused work, because the traumatic memories, so to speak, are stuck and laid down, so to speak, in right hemispheric modalities. It's imaged base, it's somatic, it has, you know, connections straight into the limbic system, in a sense, nonverbal. And so it's important that as you work with those, at that experiential level, that then you bring in the left

hemispheric modalities of language and past and future and all of that to link that up. put words to the change. Yeah. You got to put words to the change and to the transformation in the moment. Otherwise, it gets lost in a sense. So we have to constantly work at that level of assimilation. Yeah.

Because that's what couldn't get assimilated. The traumatic experience was so big you couldn't assimilate it. And rightfully so. And especially if it happens when people are very young, you don't even have the biological, a neurobiological architecture to assimilate. these horrible experiences. So of course it's going to get stuck in the nervous system, like food stuff in the psychological intestinal track.

You can't digest it or break it down. You know, one thing I'll say about that is when people are telling me their traumatic stories, even from when they were young, how the parents responded to it matters a lot. Absolutely. And I think that when we think about a big stress, the recovery that can come afterwards, can help us move out of, you know, that the trauma into something else,

into something that is not sort of continually registering in the brain is traumatic. Yeah. And that recovery comes from an attuned, caring person. Absolutely. So when my kids, you know, come to me after a very stressful event, I try to start by attuning to their emotion, you know. It's what's primal, and there's primacy in the moment is the emotion. Yeah.

It's like, out. And I try to put words to it. Yes, yes, yes. Like, I use very basic words for different emotions, like anger, pain. Yes. You know, pain is like my son sat down on a kind of a sharp surface the other day and scraped himself. And he was crying. And I, you know, that was pain.

That was a lot of pain. That really hurt. It hurts a lot right now. And I kept, you know, hold him, repeat that. Yes. He wants to get to Mommy. Mommy does a similar thing. And he goes away.

And it kind of like he snaps right out of it. Yeah. He assimilates it. Yeah. But not only does he assimilate that the thing was survivable, I'm okay, but he also assimilates the warm attunement. The warm attunement. And then that becomes integrated into his own neural architecture.

And eventually it allows him to be able to self-regulate. Exactly. Yeah. Which to some degree is what therapy occurs in therapy as well. is you get repeated bouts of learning how to regulate your emotional experience. Yeah. Okay, so now go back to like, you know, we talked about the straight face experiment. The still face.

The stiff face. The still face. But now what about children who actually experienced that? Now, when they, because all kids experience pain, they fall everywhere or they get hurt or adults are not responsible with them and treat them terribly. But they still need that attuned what Alice Miller called, like that enlightened witness. Like someone has got to come, even if it's not the parent, but somebody's got to come and say, and to notice what they're feeling, notice what's what caused it, what's going on

around it, mirror that, be empathic, be warm, eye contact, warm tone of voice, physical touch, touch, facial expression, posture that meets them, and then putting the words to it. Putting the words to it. Right? When kids don't have that, that's a trauma. It's a stress that doesn't get sort of catabolized. So the way that I understand, digest it. One of the errors of a lot of parenting books is they don't talk about stress and the beneficial effects of

someone going through sequential stresses. Uh-huh. So what I see is some kids get to a point where they're in high school. And the parents have been so hypervigilant to decrease any stress that when any little stress comes, they pull the kid out of that thing, or they don't allow the kid to continue, or they do for the kid what the kid needs to do for themselves. Yes. Okay, so that's an important point too.

So that's another kind of neglect is the neglect of allowing them to have what the early child psychoanalyst talk about is the optimal frustration. You have to allow the child to encounter stressful experiences, work with them, partner with them, and getting through that so that they can assimilate that they actually can manage it and that they have progressively the internalized skills and techniques. to be successful in managing life stressors. You don't grow without stress. Well, now we have a lot of kids nowadays who are lay high school, early college, who are constantly looking outside of themselves to the social structures to manage them.

And to shield them from having discomfort, that's not going to serve them. And I think this is where, like, if you look at some studies on, the benefits of sports and stuff for kids. I think this is what makes a lot of sense to me. Is, you know, being on a wrestling team, there's stress. There's real stress there.

Now, how do you help someone like that recover? Well, you help them put words to things that were stressful. That's right. You can empathize with the distress, but then, you know, come back to, you know, but this is good for you. Actually, human beings seek out stress. Think of people, because that, because we know it in our gut, that that's what creates growth. And we are programmed to constantly, I think, be wanting to grow and transcend where we're out in this moment.

And so think of people who climb Mount Everest. It's one of the most stressful experiences a human could conjure up for themselves. But why do it? It's because the stress is the. catalyst for that of what coming out on the other side of it a different person right right and you know if someone was forced to go up mount Everest that would be a trauma that would be a trauma so i think there's a difference in consent yeah versus no consent um consent would be i'm choosing to allow myself to be stressed to continually be stressed and prepare for this event because there's meaning in it

Because the meaning is big enough. Yeah. The meaning is, you know. It's owned. It's, I own the meaning. Right. It's personal to me because on the other side of it, I'm going to be different in a way that I need to be different. So when a patient's come in, you know, they don't necessarily know they're getting into trauma-focused therapy.

Yeah, they just come into our office and say, I'm riddled with fear, nightmares. I can't get past where I'm stuck. and you begin to go through the assessment process, you determine what the best treatment is, do we need to refer them for adjunctive psychotropic medication, do what do we need to do, but ultimately the assessment reveals, let's say, post-traumatic stress, and then you introduce to them what is trauma-focused therapy.

And if you're open about it, you'll say you are going to encounter some stress. In the session. In the session. It is hard to do this work. Yes. People sometimes decompensate for a week after a really tough session. The session could still be a catalyst towards their overcoming. Well, the research on psychotherapy outcome that looks at over time the sessions that made the difference in a course of treatment were the ones that were the most emotionally impactful.

Not emotionally traumatic, but emotionally impactful. Okay. And I think that a good therapist knows where to limit the amount of the amount of that stressfulness in a session. Absolutely. Just like a good coach, a good sports coach would know, you know, no, this team is getting way too exhausted. And I should not continue to push them at this point. I should allow them to recover and then I'll push them again next week. Okay. So let's park there for a moment, because this goes back to the skill and training of the therapist to work with traumatized people using trauma-focused therapy. If you don't understand what the different signs of the different nervous systems activation are, if you can't differentiate between what is the activation of the somatic nervous system and then in the autonomic,

the sympathetic versus the parasympathetic. If you can't determine what are the signs of the activation of those different branches of the nervous system, you are not going to be able to titrate the stress, so to speak, where the patient can manage it. Yeah. If your patient starts shading into severe parasympathetic activation. Like the dorsal vagal, the shutdown, dissociating. Yes, all of the dissociation, all of the distancing, all of the muscle tone give out, all of that stuff. if you think, oh, I just need to keep pushing them,

you're going to harm the patient. But if you can keep an eye on, where's that threshold? And then pull it back. Yeah. And then bring up the cognitive part and assimilate this and work on this and notice this. And then shift the nervous system to a more balanced ventral state, let's say, in polyvagal terminology.

Yeah. And I think, you know, I think in part two, when we go into part two, I'm not sure how many parts this will be to talk about trauma with you. But in part two, we'll go through some of how we identify the different systems.

Yeah, yeah, yeah. This is a part, this is something I teach my students and trainees very much on identifying, and I learned this from Habib Davanloo's work, by the way, an intensive short-term dynamic therapy. We'll see how it compares to the stuff

that I've studied. Yeah, yeah. Because I haven't studied him in particular, but I've, you know, I've come to my own sort of understanding of this, through the polyvagal theory and through Bessel van der Kolk and Peter Levine. Well, it's all based on the same nervous system, so no doubt there'll be a lot of overlap. Yeah.

So in part two, I think we'll touch on some of the neurobiological correlates. We'll talk about a little bit more on the process of therapy and how to move people through the states. And let's highlight some of the specific trauma-focused therapies, at least some of their just main distinction. names and how they're similar, how they're different. And then maybe go into a bit on what are some of the more specific symptoms of post-traumatic stress and how to identify that in your patients and things like that. So to summarize, what are the big takeaways that you would want someone to have after listening to this? Well, I think we have a very rich dialogue here.

And I think that some of the things that stood out to me are you can't do good trauma-focused, where I think you can't do good therapy, period, but you can't do good trauma-focused work without understanding how the nervous system is organized, how the brain is organized, and how to identify when the various brain systems are in operation so that you can almost like a dance kind of craft and co-create the experience with the patient that ultimately helps them assimilate something new in the things. therapy with you? I think my big takeaways would be the importance of the therapeutic alliance, the importance of connecting with the patient in the midst of early on and also in the midst of doing the work, the importance of understanding where someone is at based on, you know, our understanding of neurology and like you said. And then I think the third thing would be starting to

talk about some of the things that are important to doing this work. Whether, you know, the frame, the boundaries, the, you know, some of the areas of difficulty that come up. Yeah. With like the transference and, and also kind of thinking through, you know, okay, is this a single trauma or is this a developmental trauma? Exactly. Is this someone who experienced that still face all growing up?

Or is this someone who went through one discrete. event where they have a traumatic experience. Yeah. And then the last thing I think that was really important, well, two things. One was how to receive feedback. And the second one was not all stress is bad. That's right. And we can have sequential stresses in our life that help us grow.

Yes. And I think that's where for me, the strength training, the sports. Yes, yes. And doing the therapy, doing the hard work is very important. important in that process. And I think that also the important to that point, the important aspect of that we are kind of in a sense, there's something inside of us that wants to transcend where we're at. Yeah. Absolutely. And we can only do that through embracing stress, but we have to be kind of prepared to be able to do so, and so that we can go through it in a way

that we come out different in the way we want to be different. Yeah. Yeah, that's good. I think Gosh, one last thought on that was how like, think about like how the military trains people. Yes. Because if you think about like the outcome, like here you have a warrior who's able to be in battle and to not dissociate. Absolutely. And to not experience this as trauma. Now that not that some people still experience things as trauma, but in general, most of them don't

experience what happens on the battlefield as trauma. And it's a sequential of stresses that lead them to that place. And I think it's the same thing for athletes. You know, if you think about what they're actually. doing on game day. That could be so that could be traumatic for like someone who's forced to do it, who didn't want to do it and who's going at the same level, but the sequential to do it. Yeah. The sequential process. So I think that's a good sort of allegory to what good trauma therapy is like.

Yes, yes, yes. Where you're sequentially meeting with someone, it's somewhat stressful to do it to process these things again. You don't really want to discuss them again. but in the process of being able to go discuss it again and connect with the individual in front of you, that's the very basics of what will help you overcome it. Well, and it depends on the patient because when I was doing my EMDR training and our trainer was talking about

how he spent just an entire year doing nothing but preparing the patient, resourcing the patient, teaching them ways to break out of dissociation and refocus in the present in all five senses. That's good. I mean, just a whole year of doing nothing but that before ever embarking upon the, let's say, the stress part.

So absolutely. I'm looking forward to our future dialogues on this. All right. Thank you, Randy. Stenet. Yes. I will see you soon.