Treating PTSD

In a previous post I described the basics of the diagnosis of Post Traumatic Stress Disorder (PTSD).  Now a little about treatment. 

I have found PTSD to be one of the disorders that responds best to treatment.  In the last 20 years (not a long time in the history of mental disorders) there has been a huge increase in the understanding of the problem and the ways of effectively treating it.  The International Society of Traumatic Stress Studies and The International Society for the Study of Trauma and Dissociation have supported much research and training and continue to do wonderful work.  The therapists that I work with have all participated in training from these organizations and I look forward to attending as many of their events as possible. 

We now expect the return of a large number of military veterans from the wars in Iraq and Afghanistan in addition to the people in other occupations who have experienced terrible events.  Some of these people will have problems with PTSD.   In recent news reports, I have heard that there are not yet enough therapists trained to treat these people.  Recent Congressional testimony has addressed this ongoing problem in regard to the resources of the Veterans Affairs organization. 

If you know of someone who might have PTSD (or might be one), it would be a good idea to get it checked out.  There are resources out there, the internet has lots of links and pages for interested people. While some medications can be helpful in the treatment of PTSD, psychotherapy is the primary method of treatment.  Taking a pill won’t make it go away.  When selecting a therapist, ask if they have any specialized training and are aware of the recommended treatments of PTSD (the Standard of Care).  As always, be an informed consumer. 

Bill Bonacker

What is PTSD?

PTSD is the abbreviation for Post Traumatic Stress Disorder, a condition defined officially in the diagnostic manual of the American Psychiatric Association.  PTSD is also increasingly in the news and in popular publications associated with the controversy about whether the diagnosis should be given to some members of the Military Services.  There is some uncertainty and confusion about what it really is and I hope I can add some basic clarity.

Psychologist John Read has said “bad things happen to people and it screws them up” – the basic concept behind PTSD.    The official diagnosis is, of course, more complicated (about 6 pages in my copy of the diagnostic manual) and specifies what “bad things” (trauma) and what kinds of problems qualify.  It is also important to remember that not everybody who goes through a terrible experience has serious problems. 

When people who experience traumatic events do have serious problems they come in particular types.  As I wrote in previous posts, people can experience an increase in the amount of time that their minds and bodies spend “on red alert”, prepared for more trouble.  This kind of problem can be a high level of anxiety or tension, being “jumpy” (we call this an exaggerated startle response), being unable to relax or sleep well, poor concentration and others.

An additional kind of problem that people with PTSD experience is an unwanted remembering of the trauma which can include dreaming about it, feeling like it is happening again and being upset when they run into situations where they are reminded of the trauma. 

The third type of problems involve trying to avoid reminders of the trauma.  We usually see people avoiding people, places or activities that remind them of the traumatic experience, a decrease in feelings (called numbing) drug/alcohol use and other ways of avoiding. 

Bill Bonacker

Coping or Curing?

Coping or Curing?

Being mindful requires that we be realistic and honest with ourselves and others. This is important because people who are facing difficulties such as grieving or anxiety tend to construct contingencies (I often think of them as “alternate realities”) by which they seek to eliminate the source of their distress before they move forward with their life, goals, etc. It’s a sort of “if, then” scenario which they seemingly demand or expect be satisfied before they will return to normal existence. We also refer to it as “bargaining” because it’s as though the situation can be changed for the better if only we can promise something enticing enough for fate to change the outcome.

An often heard comment from many of the people I see in therapy goes something like this: “I feel like I’m being told to just get over it and get back to (work, school, the task at hand, etc.).” In this scenario, it appears that people are waiting for their distress to disappear before they reengage in activities that they find difficult due to their distress. Around and around it goes, because which will happen first? Will they return to normal activities, or will the distress disappear? That is a question that they are unable to answer satisfactorily.

They are often angry, sometimes not so much because they are being asked to fulfill their obligations or duties, but because they believe they are being told to “get rid of” their distress first. This is where I am quick to jump in and totally agree with them. They cannot just get rid of their distress, and it would be totally unrealistic to expect such a thing. But, and this is the tricky part, that does not mean that they can’t still function. The right question to ask is: how does a person learn to cope with distress while fulfilling other obligations? Coping with an issue is NOT the same as resolving an issue. Coping can buy time during which someone can work on resolving the source of their distress, and in the mean time still function at a high level. While it is normal and understandable that people engage in bargaining and contingencies before moving on, ultimately the bargains will not be fulfilled and history will not be rewritten. While the love and support of friends and family can be invaluable, you may sometimes find that you need the help of a professional who understands the subtleties between coping and being cured. Make sure you get the kind of assistance that helps you truly move forward.

Mark E. Hankla

How Much Fear? Part 3

How Much Fear? Part 3

Part two of this series of posts describe some of Gavin de Becker's ideas about intuition and making predictions about dangerous behavior. In his book, The Gift of Fear, Mr. de Becker writes that the solution to violence is the acceptance of reality. One aspect of this reality is the understanding that people have reasons for being violent. de Becker describes a system for gaining this understanding. He calls it "the algebra of aggression."

An easy way to remember the elements of the algebra of aggression is the acronym J ACA. J refers to justification. People will act aggressively if they feel justified in using aggressive behavior. There are many ways in which people can justify their behavior, aggressive and otherwise. These can be reasonable such as the use of aggression to escape a life-threatening situation or less reasonable. An example of a less reasonable justification would be rationalizing your use of aggressive behavior just because someone was driving badly.

The first A in J ACA stands for alternatives. People will act aggressively if they feel it's the only or best alternative in meeting their needs. Teaching people nonaggressive alternatives to getting their needs met can be an important part of therapy. The goal is to help people recognize that they are not out of options and their only alternative is aggressive action.

C is for consequences. When the consequences of aggressive behavior are acceptable, people are more likely to behave aggressively. If they stop and think about the consequences of aggressive behavior and recognize that the consequences are serious and ongoing problems for them, the likelihood of aggression decreases.

The second A in J ACA is ability. Does the person have the ability to behave aggressively? While almost everyone has the ability to be aggressive, the degree of aggressive ability may range from verbal complaining and rudeness to the use of a weapon. Good to know.

If your mind and body are telling you that you may be in a dangerous situation with someone, figuring out that person’s justification, alternatives, consequences and ability might help you understand important information and respond to your fear in the best way possible.

Bill Bonacker

Shame and Behavior

Shame and Behavior

Of all of the influences on behavior, shame may be one of the least understood. Shame influences and warps behavior in multiple ways. This includes behaviors such as isolating and avoidance, and often leads to behaviors that make things worse. For example, a person who is consumed by shame may try to avoid people or activities that remind them of what they feel ashamed of. It may also result in deception, or lying about the issue to avoid having to face it.

One can easily see how such behavior can cause further issues, effectively digging a deeper hole for the person who already feels ashamed. We see it often in therapy, both as a personal issue and as a source of frustration or anger when interacting with others who are affected by shame. For instance, I often hear parents expressing anger at their children who “lie” or “fib” as though the child is doing so just to be deviant or defiant of them, and they take it personally. But many times when the child is questioned about the behavior, it becomes evident that the deception is due to a desire to not disappoint the parent, which is the opposite of how the parent perceives it. An example might be when a child “lies” about not having homework or says it is already done even when it is not. It might be that the child just doesn’t want to do the work and is trying to get out of it. But it also possible that the child is ashamed that she or he didn’t get the work done already, or doesn’t understand it, or is afraid they won’t do it well enough. Either way the behavior is an issue that needs to be addressed. However, to address the behavior effectively it is important to understand the etiology of the behavior.

People feeling shame tend to avoid others, hiding their activities, avoid eye contact, and are quieter than usual. People feeling proud or happy tend to share their experiences or triumphs, feel more confident around others, and tend to look directly at others while maintaining eye contact. These are markers or indicators that you can use to monitor your own, or other’s, level of shame and vulnerability. If you notice your behavior is indicative of feeling shame, it may be time to discuss your feelings with a trusted friend or with a professional to help you relieve the distress, and help you improve your confidence and self-esteem. Shame can be dealt with so it does not negatively affect behavior.

Mark E. Hankla

How Much Fear? Part 2

How Much Fear? Part 2

In the previous post, we talked about the physical and psychological parts of our fear response. Published in 1997, The Gift of Fear by Gavin de Becker gave us some additional ways of looking at fear. In addition to recommending this book to many clients, our organization also provides a copy to anyone who comes to work here. The subtitle of the book, survival signals that protect us from violence, points to its main emphasis - how do we identify what is truly dangerous and avoid harm?

Mr. de Becker talks about using our intuition to identify danger and to guide us towards safety. He helps us to gain a greater understanding of intuition by listing "the messengers of intuition." These are: nagging feelings; persistent thoughts; humor; wonder; anxiety; curiosity; hunches; gut feelings; doubt; hesitation; suspicion; apprehension; and fear. If you take some time to think about your experiences with these thoughts and feelings, you may be able to remember what they told you or what you should have learned from their presence.

de Becker’s book contains real life examples of dangerous situations that illustrate the points that he is making. He also describes ways of making predictions about dangerous behavior and situations.

After reading his book, I found myself thinking about dangerousness and fear differently. Instead of something to be avoided, fear has become another piece of information. Information that is essential in making important decisions.

Bill Bonacker

How Much Fear?

How Much Fear?

We all know that there are many things to be afraid of. Bad economic conditions, health concerns and, sometimes, other people. We also know that when we are afraid, our bodies and minds experience changes. In his extensive work as a military psychologist, Dave Grossman has written about the effects of fear. He has described five levels or "conditions" and the effects of each of them.

In condition white, we experience our normal resting heart rate and feel calm and relaxed. As we become more alarmed, our heart rate rises from a normal rate of 60 to 80 beats per minute (bpm) through condition yellow (around 100 bpm) to condition red (from 115 to 145 bpm). Dr. Grossman says that in this range, we are at our best for performing complex physical activities and have optimal reaction time for responding to danger. This is not a comfortable state.

If we become even more distressed, our heart rate increases and our bodies experience additional changes. Breathing speeds up. We become less effective. Our ability to make complicated decisions decreases we experience changes in vision and hearing and most of our bodies resources are dedicated to simple physical activities important to survival. This is the state commonly known as "fight or flight." Dr. Grossman labels this as condition gray. Above 175 bpm, we enter Dr. Grossman's condition black. Our thinking may become irrational; we may experience a temporary shut down or freeze. We may still be able to run or fight but doing anything more complicated is unlikely.

Obviously, these reactions have been essential to our survival for centuries. The problem is that although most of us don't run into situations that are so dangerous that conditions red and above are helpful, our bodies go there anyway. Stress and panic reactions can be triggered by reminders of past danger or intense worries about loss or harm. Learning to calm ourselves when no immediate physical danger is present becomes an important skill. In order to function but our best we need to use our physical and mental resources most effectively and stay below condition red most of the time. There are a number of ways to do this ranging from breathing exercises to changing the way we think about the things that happen to us. In future posts, I'll go into more depth about managing our fear reactions. For now, remember to breathe.

Bill Bonacker