Tag Archives: trauma

Counseling and Psychotherapy Theory and Practice

Revisiting the Genius of Mary Cover Jones

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While reviewing and revising the behavior therapy chapter from our Theories textbook, I found myself revisiting my awe of Mary Cover Jones. I think too many contemporary therapists don’t know about Mary Cover Jones and don’t understand the behavioral (classical conditioning) model for understanding and treating anxiety disorders, including OCD and PTSD.

In most chapters, we include a feature called a “Brain Box.” Here’s the box from Chapter 7, Behavior Theory and Therapy.

7.1 Brain Science May be Shiny, but Exposure Therapy is Pure Gold

In honor of Joseph Wolpe, let’s start with mental imagery.

***********

Imagine you’ve travelled back in time to your first week of high school. You look around and see that one of your classmates is named Mary Jones.

Mary is an ordinary girl with an ordinary name. Over the years, you don’t notice her much. She seems like a nice person, a fairly good student, and someone who doesn’t get in trouble or draw attention to herself.

Four years pass. A new student joined your class during senior year. His name is Daniel Tweeter. Toward the end of the year, Daniel does a fantastic Prezi presentation about a remarkable new method for measuring reading outcomes. He includes cool video clips and boomerang Snapchat. When he bows at the end, he gets a standing ovation. Daniel is a good student and a hard worker; he partnered up with a college professor and made a big splash. Daniel deserves recognition.

However, as it turns out, over the whole four years of high school, Mary Jones was quietly working at a homeless shelter; week after week, month after month, year after year, she was teaching homeless children how to read. In fact, based on Daniel’s measure of reading outcomes, Mary had taught over 70 children to read.

Funny thing. Mary doesn’t get much attention. All everybody wants to talk about is Daniel. At graduation, he wins the outstanding graduate award. Everyone cheers.

Let’s stop the visualization and reflect on what we imagined.

***********

Like birds and raccoons, humans tend to like shiny things. Mary did incredible work, but hardly anyone noticed. Daniel did good work, and got a standing ovation and the top graduate award.

The “shiny-thing theory” is my best explanation for why we tend to get overly excited about brain science. It’s important, no doubt, but brain imaging isn’t therapy; it’s just a cool way to measure or validate therapy’s effects.

Beginning from at least 1924, when Mary Cover Jones was deconditioning fear out of little children, behavior therapy has shown not only great promise, but great outcomes. However, when researchers showed that exposure therapy “changes the brain,” most of the excitement and accolades were about the brain images; exposure therapy was like background noise. Obviously, the fact that exposure therapy (and other therapies) change the brain is great news. It’s great news for people who have anxiety and fear, and it’s great news for practitioners who use exposure therapy.

This is all traceable to neuroscience and human evolution. We get distracted by shiny objects and miss the point because our neural networks and perceptual processes are oriented to alert us to novel (new) environmental stimuli. This is probably because change in the form of shiny objects might signal a threat or something new and valuable. We therefore need to exercise self-discipline to focus in and not overlook that behavior therapy in general, and exposure therapy in particular, has been, is, and probably will continue to be, the most effective approach on the planet for helping people overcome anxiety and fear. In addition, you know what, it doesn’t really matter that it changes the brain (although that’s damn cool and affirming news). What matters is that it changes clients’ lives.

Exposure therapy, no matter how you package it, is highly effective for treating anxiety. This statement is true whether we’re talking about Mary Cover Jones and her evidence-based counterconditioning cookies or Francine Shapiro and eye movement desensitization reprocessing (EMDR). It’s also true whether we’re talking about virtual reality exposure, imaginal exposure, massed exposure, spaced exposure, in vivo exposure, interoceptive exposure, response prevention (in obsessive-compulsive disorder), or the type of exposure that acceptance and commitment therapists use (note that they like to say it’s “different” from traditional classical conditioning exposure, but it works, and that’s what counts).

In the end, let’s embrace and love and cheer brain imaging and neuroscience, but not forget the bottom line. The bottom line is that exposure therapy works! Exposure therapy is the genuine article. Exposure therapy is pure gold.

Mary Cover Jones is the graduate of the century; she was amazing. Because of her, exposure therapy has been pure gold for 93+ years, and now we’ve got cool pictures of the brain to prove it.

Mary Cover Jones passed away in 1987. Just minutes before her death, she said to her sister: “I am still learning about what is important in life” (as cited in Reiss, 1990).

We should all be more like Mary.

Cool Counseling, Happiness, Personal Reflections

Writing Your Way to Better Health

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Nothing works for everyone. Not everyone is comfortable writing about their experiences and not everyone can benefit from therapeutic writing. But, for those keen on the expressive writing modality, you can get out your pen or laptop and make a little therapeutic magic.

For this week’s Montana Happiness Challenge, I phrased it this way: What if, by engaging in a simple procedure for three consecutive days, you could obtain the following benefits?

  • A reduced need to go see a physician
  • Improved immune functioning
  • Fewer physical ailments or symptoms
  • Less distress
  • Less negative affect
  • Less depression
  • Improved GPA
  • Less absenteeism from work

As it turns out, according to social psychologist and prominent researcher, James Pennebaker, there is a simple procedure for accomplishing all of the above, right at your fingertips. Literally. At. Your. Fingertips. All you have to do is write about hard, difficult, or traumatic experiences. Here’s an example (summarized) of his instructions:

For the next three days write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life. When writing, really let go and explore your deepest emotions and thoughts. You might want to tie your writing into your relationships with others or to your past/present/future, or to who you’ve been, who you are, and who you’d like to be in the future. You can write about the same topic every day or a new one every day. Keep your writing confidential. Don’t worry about spelling, grammar, etc., just write for 15-30 minutes straight. (adapted from Pennebaker, 1997) 

I’ve been gobsmacked (aka astounded) by Pennebaker’s research for three decades. So much so that I remember where I was when I first read his 1986 article. Despite my gob-smacked-ness, I think it’s important to remember that Pennebaker is a social psychologist; he isn’t a clinical or counseling psychologist, a clinical mental health counselor, or a clinical social worker. As a consequence, I’m not asking you to leap right into his assignment without support. In fact, most researchers, including Pennebaker, believe you can gain the same benefits by talking about painful emotional experiences with a counselor or psychotherapist. One additional caveat: Pennebaker has also found that when writing or talking about traumatic experiences, often people feel distressed or emotionally worse to start, but over time they begin feeling better than they did in the beginning.

To do this activity, just think about Pennebaker’s method and his claims, and notice: (a) what you think of his idea, (b) whether you would ever like to try his technique, and (c) if you chose to try to process some deeper emotional issues, whether you would prefer writing or talking about them.

If you decide to really try Pennebaker’s method (that’s up to you), remember that your first reaction might be to feel worse. Therefore, having someone you trust to confide in about how you’re feeling through the process might be a good idea.

For me–and I know I’m weird–I like to go back and read some of the early research on these “therapeutic techniques.” Sometimes there’s no research to be found (think: somatic approaches or polyvagal theory); other times, the gaps between what was studied and what the media and popular psychology reports is huge (think: adverse childhood experiences and the research on predicting divorce); but on occasion, the original research is stunningly good. Here’s one of Pennebaker’s early studies. It’s really worth a read:

pennebaker-1988Download

If you want to dive into Pennebaker’s method, you could use one of his books as a guide. Here’s one example: https://www.abebooks.com/Opening-Writing-Down-Expressive-Improves-Health/22531442075/bd?cm_mmc=ggl-_-US_Shopp_Trade-_-new-_-naa&gclid=CjwKCAjw4pT1BRBUEiwAm5QuR4ZmBWoiw2FhWHexwZiPtAnyDc9frTptZr9dimZhEWcsE4HUl70gzxoCd60QAvD_BwE

John S-F

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention, Writing

Strategies for Dealing with Insomnia and Nightmares, Part II

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This is part II of a two-part blog. For part I, see Sunday’s post: https://johnsommersflanagan.com/2021/05/23/strategies-for-dealing-with-insomnia-and-nightmares-part-i/

Asking About Trauma

You may have a form to screen clients for a trauma history. However, more often than not, you’ll need to ask directly about trauma, just like you need to ask directly about suicidality. In many cases, as discussed in Chapter 3, it may be beneficial to wait and ask about trauma until the second or third session, or until there’s a logical opportunity. Although insomnia and nightmares don’t always signal trauma, when they co-exist, they provide an avenue to ask about trauma.

Counselor: Miguel, I’d like to ask a personal question. Would that be okay?

Miguel: Okay.

Counselor: Almost always, when people have nightmares about guns and death, it means they’ve been through some bad, traumatic experiences. When you’ve been through something bad or terrible, nightmares get stuck in your head and get on a sort of repeating cycle. Is that true for you?

Miguel: Yeah. I went through some bad shit back in Denver.

Counselor: I’m guessing that bad shit is stuck in your brain and one ways it comes out is through nightmares.

Miguel: Yeah. Probably.

Even when clients know their trauma experiences are causing their nightmares, they can still be reluctant to talk about the details. Physical and emotional discomfort associated with trauma is something clients often want to avoid. To reassure clients, you can tell them about specific evidence-based approaches—approaches that don’t require detailed recounting of trauma or nightmare experiences. Two examples include eye movement desensitization reprocessing (EMDR; Shapiro, 2001) and imagery rehearsal therapy (Krakow & Zadra, 2010). 

Miguel: If I talk about the nightmares, they get more real. I have enough trouble keeping them out of my head now.

Counselor: That’s a good point. But right now your dreams are so bad that you’re barely sleeping. It’s worth trying to work through them. How about this? I’ve got a simple protocol for working with nightmares. You don’t even have to talk about the details of your nightmares. I think we should try it and watch to see if your dreams get better, worse, or stay the same? What do you think?

Miguel: I guess maybe my nightmares can’t get much worse.

Evidence-Based Trauma Treatments

In Miguel’s case, the first step was to get him to talk about his insomnia, nightmares, and trauma. Without details about his experiences, there was no chance to dig in and start treatment. The scenario with Miguel illustrates one method for getting clients to open up about trauma. Other clinical situations may be different. We’ve had Native American clients who were having dreams (or not having dreams, but wishing for them), and we needed to begin counseling by seeking better understanding of the role and meaning of dreams in their particular tribal culture.

 Counselors who work with clients who are suicidal should obtain training for treating insomnia, nightmares, and trauma. Depending on your clients’ age, symptoms, culture, the treatment setting, and your preference, several different evidence-based treatments may be effective for treating trauma. The following bulleted list includes treatments recommended by the American Psychological Association (2017) or the VA/DoD Clinical Practice Guideline Working Group (2017), or both (Watkins et al., 2018).

  • Cognitive Processing Therapy (Resick et al., 2017).
  • Eye-Movement Desensitization Reprocessing (Shapiro, 2001)
  • Narrative Exposure Therapy (Schauer et al., 2011)
  • Prolonged Exposure (Foa et al., 2007).
  • Trauma-Focused Cognitive Behavioral Treatment (Cohen et al., 2012).

Although the preceding list includes the scientifically supported approaches to treating trauma, you may prefer other approaches, many of which are suitable for treating trauma (e.g., body-centered therapies, narrative exposure therapy for children [KID-NET], etc.).

Specific treatments for insomnia and nightmares are also essential for reducing arousal/agitation. Evidence-based treatments for insomnia and nightmares include:

  • Cognitive-Behavioral Therapy for Insomnia (CBT-I; Cunningham & Shapiro, 2018).
  • Imagery Rehearsal Therapy (IRT; Krakow & Zadra, 2010).

Targeting trauma symptoms in general, and physical symptoms in particular (e.g., arousal, insomnia, nightmares) can be crucial to your treatment plan. Addressing physical symptoms in your treatment instills hope and provides near-term symptom relief.

[Check out the whole book for more info: https://imis.counseling.org/store/detail.aspx?id=78174%5D

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention, Writing

Strategies for Dealing with Insomnia and Nightmares, Part I

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What follows is an excerpt from, Suicide Assessment and Treatment Planning: A Strengths-Based Approach (American Counseling Association, 2021). We address insomnia and nightmares in Chapter 7 (the Physical Dimension). This is just a glimpse into the cool content of this book.

Insomnia and nightmares directly contribute to client distress in general and suicidal distress in particular. In this section, we use a case example to illustrate how counselors can begin with a less personal issue (insomnia), use empathy, psychoeducation, and curiosity to track insomnia symptoms, eventually arrive at nightmares, and then inquire about trauma. Focusing first on insomnia, then on nightmares, and later on trauma can help counselors form an alliance with clients who are initially reluctant to talk about death images and trauma experiences.

Focusing on Insomnia

Miguel was a 19-year-old cisgender heterosexual Latino male working on vocational skills at a Job Corps program. He arrived for his first session in dusty work clothes, staring at the counselor through squinted eyes; it was difficult to tell if Miguel was squinting to protect his eyes from masonry dust or to communicate distrust. However, because the client was referred by a physician for insomnia, he also might have just been sleepy.

Counselor: Hey Miguel. Thanks for coming in. The doctor sent me a note. She said you’re having trouble sleeping.

Miguel: Yeah. I don’t sleep.

Counselor: That sucks. Working all day when you’re not sleeping well must be rough.

Miguel: Yeah. But I’m fine. That’s how it is.

To start, Miguel minimizes distress. Whether you’re working with Alzheimer’s patients covering their memory deficits or five-year-olds who get caught lying, minimizing is a common strategy. When clients say, “I’m fine” or “It is what it is” they may be minimizing.

But Miguel was not fine. For many reasons (e.g., pride, shame, or age and ethnicity differences), he was reluctant to open up. However, given Miguel’s history of being in a gang and his estranged relationship with his parents, the expectation that he should quickly trust and confide in a white male adult stranger is not appropriate.

Rather than pursuing anything personal, the counselor communicated empathy and interest in Miguel’s insomnia experiences.

Counselor: Not being able to sleep can make for very long nights. What do you think makes it so hard for you sleep?

Miguel: I don’t know. I just don’t sleep.

When asked directly, Miguel declines to describe his sleep problems. Rather than continue with questioning, the counselor fills the room with words (i.e., psychoeducation). Psychoeducation is a good option because sitting in silence is socially painful and because multicultural experts recommend that counselors speak openly when working with clients from historically oppressed cultural groups (Sue & Sue, 2016). The reasoning goes: If counselors are open and transparent, culturally diverse clients can evaluate their counselor before sharing more about themselves. As Miguel’s counselor talks, Miguel can decide, based on what he hears, whether his counselor is safe, trustworthy, and credible. 

Counselor: Miguel, there are three main types of insomnia. There’s initial insomnia—that’s when it takes a long time, maybe an hour or more, to get to sleep. They call that difficulty falling asleep. There’s terminal insomnia—that’s when you fall asleep pretty well and sleep until maybe 3am and then wake up and can’t get back to sleep. They call that early morning awakening. Then there’s intermittent insomnia—that’s like being a light sleeper who wakes up over and over all night. They call that choppy sleep. Which of those fits for you?”

Miguel: I got all three. I can’t get to sleep. I can’t stay asleep. I can’t get back to sleep.

Counselor: That’s sounds terrible. It’s like a triple dose of bad sleep.

As Miguel begins opening up, he says “I haven’t slept in a week.” Although it’s obvious that zero minutes of sleep over a week isn’t accurate, for Miguel, it feels like he hasn’t slept in a week, and that’s what’s important.

Exploring Nightmares

After Miguel yawns, the counselor asks permission to share his thoughts.

Counselor: Miguel, if you don’t mind, I’d like to tell you what I’m thinking. Is that okay?

Miguel: Sure. Fine.

Counselor: When someone says they’re having as much trouble sleeping as you’re having, there are usually two main reasons. The first is nightmares. Have you been having nightmares?

Miguel: Shit yeah. Like every night. When I fall asleep, nightmares start.

Counselor: Okay. Thanks. I’m pretty sure I can help you with nightmares. We can probably make them happen less often and be less bad in just a few meetings.

The counselor’s confidence is based on previous successful experiences, including using a nightmare treatment protocol that has empirical support (Imagery Rehearsal Therapy; Krakow & Zadra, 2010). Although evidence-based treatments aren’t effective for all clients, they can establish credibility and instill hope. Nevertheless, Miguel doesn’t immediately experience hope.

Miguel: Yeah. But these aren’t normal nightmares.

Counselor: What’s been happening?

Miguel: I keep having this dream where I’m sticking a gun in my mouth. People are all around me with their voices and shit telling me, “pull the trigger.” Then I wake up, but I can’t get it out of my head all day? What the hell is that all about?”

Counselor: That’s a great question.

When the counselor says, “That’s a great question,” his goal is to start a discussion about all the reasons why someone (Miguel in this case), might have a “gun in the mouth” dream. If Miguel and his counselor can brainstorm different explanations and possible meanings for the dream images, it’s less likely for Miguel to interpret his dream as a sign that he should die by suicide. What’s important, we tell our clients, is to look at many different possible meanings the unconscious or God or the Great Spirit or the universe or indigestion might be sending to the dreamer. To help clients expand their thinking and loosen up on their conclusions about their dream’s meaning, we’ve used statements like the following:

You may be right. Your dream might be about you dying or killing yourself. But our goal is to listen to the message your brain sent you and be open to what it might mean. It’s perfectly normal to think your dream was about you dying by suicide—but that’s not necessarily true. That’s not the way the brain and dreams usually work.               Some counselors use self-disclosure about dreams or nightmares they’ve had themselves. Others offer hypothetical or historical dream examples. Either way, normalizing nightmares helps clients become more comfortable talking about their bad dreams and nightmares.

To be continued . . . NEXT TIME . . . we ask about trauma.

If you’re interested in this content, you can buy the whole darn book from ACA here: https://imis.counseling.org/store/detail.aspx?id=78174

If you want the eBook, you can buy it through John Wiley & Sons: https://www.wiley.com/en-ai/Suicide+Assessment+and+Treatment+Planning%3A+A+Strengths+Based+Approach-p-9781119783619

The eBook is also available through Amazon: https://www.amazon.com/Suicide-Assessment-Treatment-Planning-Strengths-Based-ebook/dp/B08T7VNCMK/ref=sr_1_9?dchild=1&qid=1621798923&refinements=p_27%3AJohn+Sommers-Flanagan%3BRita+Sommers-Flanagan&s=books&sr=1-9

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Research

The Hottest New Placebos for PTSD

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Let’s do a thought experiment.

What if I owned a company and paid all my employees to conduct an intervention study on a drug my company profits from? After completing the study, I pay a journal about ten thousand British pounds to publish the results. That’s not to say the study wouldn’t have been published anyway, but the payment allows for publication on “open access,” which is quicker and gets me immediate media buzz.

My drug intervention targets a longstanding human and societal problem—post-traumatic stress disorder (PTSD). Of course, everyone with a soul wants to help people who have been physically or sexually assaulted or exposed to horrendous natural or military-related trauma. In the study, I compare the efficacy of my drug (plus counseling) with an inactive placebo (plus counseling). The results show that my drug is significantly more effective than an inactive placebo. The study is published. I get great media attention, with two New York Times (NYT) articles, one of which dubs my drug as one of the “hottest new therapeutics since Prozac.”  

In real life, there’s hardly anything I love much more than a cracker-jack scientific study. And, in real life, my thought experiment is a process that’s typical for large pharmaceutical companies. My problem with these studies is that they use the cover of science to market a financial investment. Having financially motivated individuals conduct research, analyze the results, and report their implications spoils the science.

Over the past month or so, my thought experiment scenario has played out with psilocybin and MDMA (aka ecstasy) in the treatment of PTSD. The company—actually a non-profit—is the Multidisciplinary Association for Psychedelic Studies (MAPS). They funded an elaborate research project, titled, “MDMA-assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study” through private donations. That may sound innocent, but Andrew Jacobs of the NYT described MAPS as, “a multimillion dollar research and advocacy empire that employs 130 neuroscientists, pharmacologists and regulatory specialists working to lay the groundwork for the coming psychedelics revolution.” Well, that’s not your average non-profit.

To be honest, I’m not terribly opposed to careful experimentation of psychedelics for treating PTSD. I suspect psychedelics will be no worse (and no better) than other pharmaceutic-produced drugs used to treat PTSD. What I do oppose, is dressing up marketing as science. Sadly, this pseudo-scientific approach has been used and perfected by pharmaceutical companies for decades. I’m familiar with promotional pieces impersonating science mostly from the literature on antidepressants for treating depression in youth. I can summarize the results of those studies simply: Mostly antidepressants don’t work for treating depression in youth. Although some individual children and adolescents will experience benefits from antidepressants, separating the true, medication-based benefits from placebo responses is virtually impossible.

My best guess from reading medication studies for 30 years (and recent psychedelic research) is that the psychedelic drug results will end up about the same as antidepressants for youth. Why? Because placebo.

Placebos can, and usually do, produce powerful therapeutic responses. I’ll describe the details in a later blog-post. For now, I just want to say that in the MDMA study, the researchers, despite reasonable efforts, were unable to keep study participants “blind” from whether they were taking MDMA vs. placebo. Unsurprisingly, 95.7% of patients in the MDMA group accurately guessed that they were in the MDMA group and 84.1% of patients in the placebo group accurately guessed they were only receiving inactive placebos. Essentially, the patients knew what they were getting, and consequently, attributing a positive therapeutic response to MDMA (rather than an MDMA-induced placebo effect) is speculation. . . not science.

In his NYT article (May 9, 2021), Jacobs wrote, “Psilocybin and MDMA are poised to be the hottest new therapeutics since Prozac.” Alternatively, he might have written, “Psilocybin and MDMA are damn good placebos.” Even further, he also could have written, “The best therapeutics for PTSD are and always will be exercise, culturally meaningful and socially-connected processes like sweat lodge therapy, being outdoors, group support, and counseling or psychotherapy with a trusted and competent practitioner.” Had he been interested in prevention, rather than treatment, he would have written, “The even better solution to PTSD involves investing in peace over war, preventing sexual assault, and addressing poverty.”

Unfortunately, my revision of what Jacobs wrote won’t make anyone much money . . . and so you won’t see it published anywhere now or ever—other than right here on this beautiful (and free) blog—which is why you should pass it on.

Cool Counseling, Happiness, Personal Reflections

Happiness and Well-Being (in Livingston, Montana)

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Cow

Yesterday, at the fabulous West Creek Ranch retreat center just North of Yellowstone Park, I introduced community leaders from Livingston, Montana to a man named James Pennebaker. It was a brief meeting. In fact, I’m not sure anyone remembers the formal introduction.

I should probably mention that James Pennebaker wasn’t in the room. The meeting consisted of me putting a short and inadequate description of one of his research studies up on a screen. The study went something like this:

Back in 1986, Pennebaker randomly assigned college students to one of two groups. The first group was instructed to write about personally traumatic life events. The second group was instructed to write about trivial topics. Both groups wrote on four consecutive days. Then, Pennebaker obtained health center records, self-reported mood ratings, physical symptoms, and physiological measures.

Pennebaker reported that, in the short-term, participants who wrote about trauma had higher blood pressure and more negative moods that the college students who wrote about trivia. But the longer term results were, IMHO, amazing. Generally, the students who wrote about trauma had fewer health center visits, better immune functioning, and overall improved physical health.

Pennebaker’s theory was that choking back important emotions takes a physical toll on the body and creates poorer health.

Since 1986, Pennebaker and others have conducted much more research on this phenomenon. The results have been similar. As a consequence, over time, Pennebaker has “penned” several books on this topic, including:

  • Opening Up: The healing power of expressing emotions
  • Writing to Heal: A guided journal for recovering from trauma & emotional upheaval
  • Expressive Writing: Words that heal
  • The Secret Life of Pronouns: What our words say about us
  • Opening Up by Writing It Down

As most of you know, after a couple decades presenting on suicide assessment and treatment, Rita and I have pivoted toward happiness and well-being. The coolest thing about talking about happiness and well-being is that doing so is WAY MORE FUN, and it results in meeting and laughing with very cool people, like the Livingston professionals.

Speaking of Livingston professionals, just in case you forgot that you met James Pennebaker, here’s a link to my powerpoints from yesterday: Livingston 2019 Final

I hope you had as much fun listening as I did talking.

Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Trauma, Suicide, and Motivational Interviewing: A Handout for BYEP Mentors

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Sunset

Trauma may be the most common underlying factor contributing to mental disorders. Unfortunately, trauma is often overlooked, partly because it can manifest itself in so many different ways. That said, here are some common definitions. Trauma always involves a stressful trigger that activates a trauma response. Because, like everything, trauma responses are brain-based and involve the body, symptoms affect the whole person.

Old, informal, and useful definitions include:

  • A stressor outside the realm of normal human experience (but sadly, trauma is all-too-common)
  • A betrayal . . . (e.g., something that should not happen)
  • Occurrence of an event that’s emotionally overwhelming

Below I’ve listed the essence of the DSM-5 definition for Post-Traumatic Stress Disorder (note that the whole idea of PTSD centers on the chronic or long-lasting effects of trauma).

Exposure to a traumatic stressor that involves direct personal experience, witnessing, or learning about events involving threatened death, serious injury, or a threat to your physical integrity. The trauma response includes:

  • Intrusion symptoms (recurring unwanted memories, nightmares, flashbacks, and triggered distress)
  • Avoidance of trauma-related thoughts or external cues
  • Negative cognitive alternations (e.g., memory gaps, no joy, etc.)
  • Arousal and reactivity (e.g., irritability, risky behaviors, hypervigilance, insomnia, startle response)

Trauma and trauma responses can be big, medium, and small. Big traumas meet the DSM-5 diagnostic criteria for PTSD or acute stress disorder. Small traumas are usually disturbing and disruptive, but the body and brain adjust to them within 2-3 days. Medium size traumas have lasting effects, but don’t meet formal diagnostic criterial, and are usually referred to as subclinical.

I like to think of Trauma with an uppercase T (like in the DSM) and all other traumas that are difficult, challenging, and require adjustment as traumas with a lowercase t.

What to Say

Sometimes trauma responses or symptoms are visible and obvious. If so, it’s good to say and do some of the following:

  • Listen and show compassion
  • Reassure participants that physical/psychological responses are normal, take up energy & need soothing
  • Note that very effective treatments are available (e.g., This American Life)
  • Brainstorm on what helps
  • Remember: A pill is not a skill
  • Link and universalize (“It’s normal to have pleasant and unpleasant reactions to things we talk about”)
  • Brainstorm on more and less healthy reactions (Using substances is a quick distraction, but not a fix)
  • Share hopeful stories (what skills can be developed?)
  • Self-disclosure can help. But be careful with self-disclosure and remember that it’s not about you

Trauma is a normal and natural human response. You may experience trauma just by listening to people talk about trauma, or you may have your own direct experiences. When in the business of helping others, be sure to take good care of yourself.

Three Suicide Myths

Myth #1: Suicidal thoughts are about death and dying.

Most people assume that suicidal thoughts are about death and dying. On the surface, it seems like a no-brainer: Someone has thoughts about death, therefore, the thoughts must be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Not true. Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.”

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

Believing in this myth can make surviving family members, friends, and helping professionals experience too much guilt and responsibility. In fact, even the most famous suicidologists say that it’s impossible to consistently and accurately predict suicide.

Tips for Talking about Suicide

We need to be able to talk directly about suicide with courage and calmness. But first, we should listen. Here’s what you should listen for in general

  • Emotional pain
  • A sense of feeling trapped or ashamed
  • Not believing that anything can possibly help to reduce the pain and misery

While listening, show acceptance, empathy, and compassion. Remember: suicidal thoughts are not signs of illness or moral failing; if you judge the person, it will make it harder for the person to be open. Also remember: when people talk with you about their suicidal thoughts, that’s a good thing, because you can’t help unless they’re comfortable enough with you to speak openly about their suicidal thoughts and feelings.

Traditional warning signs in particular

Although it’s good to know these warning signs, there’s not much research supporting the idea that anything predicts suicide.

  • Active suicidal thinking that includes planning and talk about wanting to die
  • Preparation and rehearsal behaviors (stockpiling pills, giving away belongings, etc.)
  • Hopelessness related to feeling that the excruciating distress will never end
  • Recklessness, impulsivity, dramatic mood changes
  • Anger, anxiety, and agitation
  • Feeling trapped
  • No reasons for living, no purpose in life, broken relationships
  • Increased alcohol or substance abuse
  • Immense shame or self-hatred

How should I ask about suicide?

The answer to this is always, “Ask directly.” But we can do even better than that. We need to de-shame suicidal thoughts and talk. Before asking, communicate that you know suicidal thoughts are a normal and natural response to emotional pain and disturbing situations. For example, you could ask it this way, “I know that it’s not unusual for people to think about suicide. Have you had any thoughts about suicide?”

What should I say if someone admits to thinking about suicide? You can say things like,

  • Thanks for telling me.
  • It sounds like things have been terribly hard.
  • Thanks for being so honest, that takes courage.
  • I know I can’t instantly make everything better, but I want you to live and I want to help.
  • How can I best support you right now?
  • What can we do together that would help?
  • When you want to give up, tell yourself to hold off for one more day, hour, minute—whatever you can.
  • Or . . . use your good listening skills and reflect back the feelings and thoughts that the person shared.

Resources for Help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

What is Motivational Interviewing?

Motivational interviewing (MI) is an evidence-based approach to treating substance problems, health concerns, and other mental health issues. MI is “person-centered” and based on the foundational principle that clients should be the ones who make the case for change in their lives. MI:

  • Focuses on the common problem of ambivalence about change.
  • Relies on four central listening skills (OARS): open questions, affirming, reflecting, and summarizing.
  • Helps clients transition from less healthy to more healthy behaviors

Four overlapping components combine to create the spirit of MI:

  • Collaboration (partnership; dancing, not wrestling)
  • Acceptance (UPR, accurate empathy, autonomy, affirmation)
  • Compassion (honoring the client’s best interest)
  • Evocation (tapping the client’s well of wisdom)

MI is a specific treatment approach that requires professional training. However, operating on a few basic MI principles can improve nearly anyone’s approach to helping others. For more information, see the book: Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY: Guilford Press.

This handout is from a mentor workshop for the Big Sky Youth Empowerment Program. These ideas are based on research and collected from professionals who have experience working with people who are feeling suicidal. These guidelines should not be considered medical advice and are no substitute for getting an appointment with a licensed health or mental health professional. See: johnsommersflanagan.com for more information.

Counseling and Psychotherapy Theory and Practice, Personal Reflections

A Book Review of Trauma-Sensitive Mindfulness by David A. Treleaven

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Ocean ViewThis weekend in Missoula is the Annual Montana Book Festival, so I’ve got books on my mind. In a stroke of good fortune (and thanks to Susan O’Connor and Rita), last night I got to meet David James Duncan, the author of my all-time favorite book, The Brother’s K.  Talking with DJD was ALMOST as fun as reading The Brother’s K, which, if you haven’t read yet, should be on your reading list.

Speaking of Davids and books, several days ago one of our fantastic UM Doc students and I had a book review published in the Journal of Contemporary Psychotherapy. The Doc student’s name is Ariel Goodman (not David), and I have the bragging rights (and honor) of being the co-author of her first (of many to come) publication.

Our review is of Trauma-Sensitive Mindfulness by David A. Treleaven. Ariel and I both liked the book. Although we take him to task a bit for less than perfect scientific rigor, overall the book is very well written and has many excellent ideas about how to safely employ mindfulness with individuals who have previously experienced trauma.

Here’s the review: Goodman-Sommers-Flanagan2018_Article_DavidATreleavenTrauma-Sensitiv

Also, thanks to James Overholser, editor of the Journal of Contemporary Psychotherapy, for giving us the opportunity to do this book review.

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Memories of Memorial Day: How to Use Memory Re-consolidation to Cope with Pain from the Past

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Green Shadow II

Back in the 1970s, I remember singing the lyrics to, The Way We Were, along with Barbra Streisand. Using my best falsetto, Barbra and I crooned, “Memories, light the corners of my mind.”

These lyrics aren’t technically correct. But then Barbra and the song’s lyricists, Alan and Marilyn Bergman, didn’t have access to modern brain scans. Based on neuroscience research, it would have been more accurate for Barbra and I to sing, “Memories, light the center of my mind.”

Memories live deep within the brain. If you could magically poke your index finger down through the top center of your skull, you still couldn’t quite reach your brain’s memory structures, the hippocampus and amygdala.

Memories are a fascinating electrical, molecular, cellular, and inter-structural phenomenon. I won’t be providing scientific details about memory, because then I’d have to write something about how the interaction of glucocorticoids and noradrenaline in the basolateral region of the amygdala can modulate the strength of memories in the hippocampus and other brain areas . . . and by then our fascination with memory would doubtless give way to boredom and sleepiness.

Speaking of sleepiness, it’s metaphorically accurate to say that most of our memories typically just lay around dozing in their hippocampal bed until awakened. Not surprisingly, some memories are lighter sleepers than others; they can be easily awakened. Sometimes, when sleeping memories are rudely awakened (triggered) they tend to be rather grumpy and unpleasant.

Here are three examples:

Say you’re creeping around on Facebook. You see an old high school photo from 25 years ago. The visual stimulus of the photo is a memory trigger; several related images and narratives pop into your mind. These images and narratives aren’t grumpy or unpleasant. Instead, you feel warmly nostalgic. This is an example of a visual trigger that activates a mildly pleasant set of associated memories.

In contrast, if you’re a veteran who has experienced war trauma and you hear firecrackers on the 4th of July, your consciousness may flood with vivid, multisensory memories. These memories could link to deep emotional pain. This is an example of an auditory trigger that awakens or activates disturbing memories—memories that you might prefer to put back to sleep.

Now, think of the smell of coffee in the morning. For me, the scent of coffee is neutral. No clear memories are activated. But, when coffee smells are combined with the aroma of bacon on the griddle, I have instant flashbacks to my Grandma Lucy making breakfast. This is an olfactory stimulus triggering a pleasant memory. I see my grandma’s grey hair, pulled back with bobby pins. I can see my own small hands touching and feeling the textured floral pattern on her white milk glass china as I wait for breakfast, watching her. I hear the pop of bacon sizzling. I can imagine the pain I might feel if I get too close to grandma’s griddle. I instantly know the past and future of this memory. First, Grandma Lucy peeled the bacon apart, dangling each piece before laying them on the griddle. Later, she’ll save the bacon grease, for another purpose. She was like that. Another emotion emerges. I feel sad. I miss her.

In honor of memory science, it’s important to note that each of the preceding memories may be more or less historically accurate. Even more important is the likelihood that these memories, like all memories, have changed, shifted, and evolved over time.

How can memories change? Isn’t it true that humans have an experience and then store a record of it in their brain, ready for later retrieval? Not exactly.

As it turns out, new memories are more fluid than solid. Following a memorable experience, memories stay unstable for somewhere between a few minutes and a few hours. New memories are in flux and shaped or degraded by additional new experiences that immediately follow. More remarkable is the fact that, even after storage, every time memories are pulled out (or retrieved) they return to an unstable or vulnerable state, until they re-stabilize or reconsolidate. And when they reconsolidate (a process that involves cellular protein synthesis), they can include new, different, or less information. This is how and why memories change over time.

For many Americans, Memorial Day is an intentional memory day. For example, yesterday there were flowers, speeches, and flag waving. Yesterday, you were probably in the company of family, possibly kneeling at a gravesite, perhaps celebrating the life of someone whom you loved and lost.

Memorial Day is a memory trigger. It’s a time set aside to honor the lives of men and women who died in service of our country. It’s natural and good to engage in this honoring ritual. People also honor non-military family members with flowers and graveside visits. But, amidst the celebrations, as is often the case, the emotional side of life gets short shrift. Typically, we celebrate and move on, despite the fact that it’s equally natural and good to honor the grief that we feel in response to Memorial Day celebratory rituals.

It might have been the 21 gun salute or the color of the flowers or the taste of the potato salad or the smell of your uncle’s cologne. Whatever the case, yesterday you probably had old memories awaken and stroll past you in an internal memory parade. Some of these memories may have been neutral. Others may have been pleasant. Still others, felt angry, sad, guilty, or lonely.

But memories are open to change, and that fact begs for intentionality. What I mean is that we should all have a plan for Memorial Day (and then a plan for Memorial Night). Not only do we need plans for how to celebrate, we need plans for dealing with the raw emotions that Memorial Day can trigger.

I wish I could offer up a simple method for helping you to deal effectively with Memorial Day memory activation and reconsolidation. But you (and everyone) are a unique entity with layers of fantastic idiosyncrasy. Nevertheless, here’s a quick glimpse into the emerging science of memory reconsolidation.

In one research study, participants were exposed to negative emotional memories from watching a trauma film. The next day, these memories were re-activated using a trauma-photo from the film. Then, after a 10 minute-break some participants played a game of Tetris, while others didn’t. The results: Over the next seven days, the participants who played Tetris after having traumatic memories re-activated, experienced significantly fewer intrusive trauma-related memories. The implications? Maybe the Memorial Night solution is to establish a Tetris-playing ritual.

But painful memories are complex and unique. What works for one person, might not work for another. As Drexler and Wolf (authors of a 2018 scholarly review) were inspired to write, “Indeed, when the activation of selective L-type voltage-gated calcium channels or GluN2B-containing NMDA receptors in the hippocampus was prevented before retrieval, thus blocking memory destabilization . . . the interfering air puff had no effect” (p. 15). Reading this led me to conclude that reading more of Drexler and Wolf’s article might serve as another possible memory disrupting intervention to employ during the reconsolidation period. I’m guessing, if you’ve made it to this point in this blog, that you’re inclined to agree.

From a practical perspective, it’s good to know that, generally, memory reconsolidation can take up to six hours. And so, in addition to Tetris and reading intellectual research papers, there are other reasonable strategies you can use to facilitate healthy memory reconsolidation, not just on Memorial Day (or Night), but any time of the year—as long as you’re within the six hour memory consolidation window.

  • Talk with a trusted friend or counselor about the emotions you’re experiencing. Even better, don’t just talk about your emotional pain, but also talk about and focus on the strengths you have for coping with your challenging emotions.
  • Engage in a physically strenuous activity. This could involve some sort of strenuous physical activity like cycling, running, yoga, or weight-lifting.
  • Ritual is good. This could involve a culturally appropriate spiritual activity like going to a sweat lodge or attending a religious service.
  • Writing is a common and effective method for expressing emotions. In particular, writing about your loss in ways that are meaningful to you can be therapeutic.
  • There may be no better way to deal with problematic emotions than engaging in positive helping behavior. Alfred Adler called this social interest. When you’re triggered, consider ways in which you can shift the spotlight away from yourself and toward fostering wellness in others.

Memorial Day is an intentional memory day. We created it and we celebrate it. But you can have other, self-created memory days. And what we know about memory and the disturbing emotions that can accompany memories, is that they present us with an opportunity. Some researchers call this an opportunity for “updating.” Recognizing this opportunity and intentionally engaging in healthy and soothing behaviors when difficult memories are activated is good guidance. This might be Tetris. It might even involve singing along with Barbra Streisand in your best falsetto. The point is that we have power, albeit limited, to update our activated memories . . . and so I wish you the best in finding intentional and healthy ways to soften your painful memories. It’s the honorable thing to do.

Counseling and Psychotherapy Theory and Practice, Parenting, Personal Reflections, Therapy with Adolescents

Talking with Kids about Trauma and Tragedy

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             All too often, very bad and traumatic things happen in the world. Many of these terrible things find their way into the news. This can be shocking and depressing not only for the people who were directly affected, but also for the general public. We are often repeatedly exposed to words and images that can trigger emotional and behavioral reactions in adults and children. Below is a short list with brief descriptions of how adults can help children deal effectively with traumatic information from the news and other media sources.

TALKING WITH CHILDREN: CONVERSATIONS ABOUT REALITY

The first step in talking with children is always the opposite of talking. LISTEN. Listen for how children have been affected. Listen for what they’ve seen and heard. Listen for their fears and fantasies. Listen for their personal coping strategies and solutions.

It’s important to listen closely, but if you listen too hard for children to talk about trauma, you run the risk of making them think they SHOULD be traumatized. If this happens, then children often will start giving you what they think you want . . . they’ll start talking about trauma. Therefore, a big challenge for adults is to listen in a balanced way.  Don’t spend too much time everyday encouraging children to talk about their deepest fears. If you do, it’s possible that everyone will get more and more scared — including you!

Perhaps the biggest deal when talking with kids about real tragic events, is being able to answer their questions. They may ask you terribly hard questions, like, “Will there be a plane crashing in our neighborhood?” or “Do you think a shooter might come to our school?” or “Will I be safe at home?” or “Teacher, are you scared?”

Children often ask very good and very hard questions. An important guideline for teachers, parents, and counselors is to stay balanced. This means you can admit to being scared — as long as you also admit to being strong. Some children can quickly pick up on false reassurance, which is one reason why I’m not in agreement with Dr. Joyce Brothers who suggested after 9/11 that it was a good time to lie to your children. Instead, I recommend acknowledgement that the world is not always a safe place, but that you’ll do everything you can to be strong and help keep the child or children safe.

With preschoolers, there are some conversational topics that are best to avoid. For example, there’s no need to go into graphic detail about specific injuries, etc.  This is similar to the fact that very young children don’t need to know all the details about sexuality. It’s better to speak generally about violence and destruction. It’s also very important to protect your children from too much exposure to media coverage of violent events.

It’s also important to never forget about focusing on children’s strengths. Listening first provides you with a foundation for giving children feedback about their strengths. Be sure to listen for children’s strengths . . . and then reflect them back. You can also encourage children to tell you about their strengths – including both ways they’ve handled hard things in the past and ways they might handle hard things in the future.

 PLAYING WITH CHILDREN: REENACTMENT, PRETEND PLAY, AND MASTERY

Younger children will typically play out or reenact their traumatic experiences. For preschoolers pretend play will be the dominant way they deal with the trauma of what they’ve seen and heard. Around 9/11 children were likely to build towers and have them knocked down. They also enacted play activities involving airplanes, police, terrorists (or other “evil/bad” people). If they’ve been exposed to images and heard about school shootings you might see some play activities involving guns and death and loss. For the most part, it’s best to just sit back and watch children as they enact these scenes. By allowing them un-directed play time and some nondirective commentary, you’ll be helping them take their first steps toward healing (more information on non-directive play is included on the “Special Time” tip sheet on this blogsite).

On the other hand, sometimes children get stuck in the same repeated play pattern. This more chronic form of play is referred to as post-traumatic play. When children seem genuinely stuck repeating pretend interactions through non-interactive play that provides no apparent gratification, you may need to interact with them in ways that help them get un-stuck. You might want to try these strategies: (a) have the child stand up and take some deep breaths before resuming play; or (b) interact with the child in a way that disrupts the pattern (for example, you might ask, “what would happen if . . . ?”).

Obviously, rigid post-traumatic play patterns indicate a need for professional assistance.

 DRAWING WITH CHILDREN:  CAPTURING THE FEAR ON PAPER

Children’s fears can seem big and intimidating. That’s true for people of any age. Maybe that’s why, for adults and older children, writing about specific fears and trauma can be so helpful. Somehow, writing things down on paper can help to put it in perspective.

Younger children aren’t able to use the written word effectively for personal journaling. That’s where drawing comes in. When children color, draw, paint, or sculpt their fears, the fears become more manageable.

 STORYTELLING STRATEGIES

Storytelling is a very powerful tradition and technique for dealing with many human problems and challenges. Stories can be designed or obtained through published materials. In response to tragedy, it can be helpful for children to hear stories of bravery under difficult or perilous conditions.

If you choose to invent your own stories, be sure to create a story with a main character and a clear beginning, middle, and ending. If you’re comfortable with it, you can even have the children help invent characters and their own stories.

There are many ways to encourage children to make up stories of their own. The advantage of this is that you get to listen for the dynamics of the children’s story and so it provides some assessment information. As a counseling technique, it’s possible to use a pretend radio or television show. You can invite children to be guests on your “show” and interview them about their experience or have them share a story.

 HELPING WITH TRANSITIONS:

Separation anxiety is a common reaction that children have to stressful news or situations. This means children may have trouble saying goodbye to their parents and being left at school or day care. In most cases, it’s best for parents, children, and staff to develop an individualized goodbye and hello routine for drop-offs and pick-ups. These routines will be less necessary as time goes by, but it’s good to have goodbye and hello rituals there when you need them. For example, having a hello and goodbye song, transitional objects, and other objects of comfort can ease the pain of separation.

 HAVING FUN: USING DISTRACTION, HUMOR, AND PLAY TO MOVE PAST TRAUMA

Don’t forget, it’s easy to pay way too much attention to the traumatic news and ignore regular daily play routines. Don’t fall into this trap. It’s good to keep kids active and keep them having fun. It’s good to be prepared with some games, songs, or activities that you can rely on to engage children and help them forget about the bad news for a while.

 LEARNING ACTIVITIES: MASTERY THROUGH EDUCATION, SAFETY, AND SERVICE

Not only does life go on after a trauma; it’s important for life to keep getting better. Ways to move forward include (a) continuing with educational, skill-building, and stress management activities, (b) promoting safety strategies and skills, and (c) involving children in basic service activities . . . possibly even service activities that include teaching other children strategies for coping with trauma or difficult situations.

 GET HELP AS NEEDED

It’s a sign of strength to get help when it’s needed. You may notice specific reactions or experiences in children or yourself that indicate it’s time to for professional assistance. Some of the primary symptoms of trauma and vicarious trauma that can develop in these situations include the following:

  • Repetitive and intrusive thoughts and images.
  • Sleep problems: Insomnia, nightmares, and night terrors.
  • Separation Anxiety and clingy-ness.
  • Specific fears/phobias.
  • Hypervigilence.
  • Regression.

 SELF CARE NOW AND INTO THE FUTURE

Remember to take good care of yourself so you can be of greater help for others. This could involve many different activities including vigorous exercise, maintaining healthy eating and sleeping routines, and scheduling time for social contact and social support.

This Tip Sheet was written by John Sommers-Flanagan, Ph.D., professor of Counselor Education at the University of Montana.