Podcast: The Truth About Trauma

Jenn talks to Patricia Mangones, PMHNP-BC. They discuss the complexities of psychological trauma and PTSD, signs and symptoms of these conditions, and ways to help navigate emotionally traumatic experiences.

Patricia Mangones, PMHNP-BC, is a nurse practitioner at McLean Hospital’s Hill Center for Women, where she works on a multidisciplinary team. She provides trauma-informed medication management in individual treatment and facilitates dialectical behavior therapy (DBT) and skills-based PTSD groups.

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Episode Transcript

Jenn: Hey everyone, welcome to Mindful Things. The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi, folks. And thank you so much for joining us for our session today called The Truth About Trauma. I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital.

And given how deeply stressful this pandemic and I don’t like the last 20 plus years have been so far. It’s totally normal to feel affected by traumatic events that occur, but trauma can impact so many parts of our lives. It can live under the surface and be dormant and it can affect each one of us pretty differently. So how can we better understand trauma and how to navigate the condition, whether we’re impacted by it or a loved one is?

So, I’m really fortunate to have Patricia with me today to help me unpack all of these intricacies of trauma, ways that we can navigate traumatic experiences. We’ll talk about the signs and symptoms of it and more as we work to further destigmatize the condition. So, if you are unfamiliar with her, Patricia Mangones is a nurse practitioner at McLean Hospital’s Hill Center for Women. She provides trauma-informed medication management and individual treatment and she also facilitates dialectical behavior therapy and skills-based PTSD groups.

So, Patricia, hi, and thank you so much for joining me today. So, I want us to get started by asking you, it’s a question that seems basic, but I think is going to be pretty loaded, can you explain what psychological trauma actually is? Because I know the word is really often used and I want folks that are joining to understand exactly what we’re talking about today.

Patricia: Yeah, exactly what you’re saying. It is a fully loaded question. So, thank you, Jenn, for having me. I am so honored to be here and to share some of my knowledge with all of you. I’m going to just start off with talking a little bit about what trauma is based on our DSM. And then I’m going to expand it a little bit to include so many other things that we are experiencing, especially recognizing that we are in a global pandemic right now.

So, to start off, according to the APA trauma is really about emotional and psychological responses to death, serious injury, violence, and the threat of all of those things. It can also include learning about the death or injury of someone close to us. That can be a close friend, family member. And most recently in the DSM-5 they also included about vicarious trauma and the idea that when you are a person who hears about trauma from other people all the time that that can also impact you and that can also lead to trauma and the same symptoms happening.

So, one of the things that I wanted to expand on is the idea that it’s more than just that. Sometimes it can feel like more than just that threat of death, it can feel like more than just that threat of violence but it can also be the emotional and psychological response to a tragic event, or a life-changing event, or a disturbing event. And sometimes that’s not fully encapsulated in that definition that the DSM gives us. So, I want to hold on to that piece around, there is so much that’s happening in the world right now, and a lot of those things can also be traumatic.

So, thinking about that, I did want to pause for a second to just recognize we are one year out from when the global pandemic started and we have all been impacted, right? I don’t think I can say that there is not one person who has not been impacted by this. There has been so much loss, so many deaths, so many things that we’ve had to change about our everyday life. We’re wearing masks all the time, that’s become the new norm to have a mask on and it’s just become one of our accessories these days.

We also are Purelling so much on our hands that they are dry and cracked. And thank goodness winter is over. We have changed so many things about how we’re in work. So, we’re doing this webinar as opposed to doing things in person. We are meeting with each other and talking through the internet, through our computers where we’re in Jetsons. So many pieces of this have been changed and I want to hold on to that piece around grieving. How much loss we’ve all experienced.

The other piece that I want to take into consideration too though is that there’s no one who is immune from trauma. No matter what you do in life so many things can happen. Situations can feel out of your control and you just can’t run away from it, you can’t escape it. So, with that I want to hold on to that piece but also recognize that everyone responds differently. So, thank you for sharing that piece because everyone responds so differently. It can look so different for so many different people.

And also holding onto that other piece around how we are all in this storm of this global pandemic together but not everyone has the same resources coming into it. So, there is definitely a difference in terms of impact that this storm that we are weathering right now has done to different people based on their own situations. So, with all of that nice, big, long answer that is fully loaded, and I’m sure that we’ll get even more into it, but that’s my basic answer for it.

Jenn: So, I know a lot of folks have said if they go through a traumatic experience the first thing that comes to mind for a lot of people is oh, it must be PTSD. But there’s so much more to trauma than that. And I also know that there’s a condition called acute stress disorder that can come out of trauma as well. Do you mind explaining the difference between these three conditions?

Patricia: Absolutely, so I think we just give a definition for trauma and a traumatic experience. So, with acute stress disorder and PTSD those are both diagnoses that are in the DSM. And so, with those come a lot of criteria. So, the DSM is what we use to help to diagnose people when they come to us with symptoms so that we have a way to understand people. We have a way to put these symptom categories together to try to find the best way to help people.

So, with acute stress disorder and with PTSD the symptoms are a lot the same. The major difference that happens with these is in terms of how many and how they show up as well as that piece around how long. So, with acute stress disorder, if you’re experiencing at least nine of these symptoms between the days of three days post-exposure to up until a month that would be considered acute stress disorder. If these symptoms occur later on and the categories are going to be a little different when it comes to PTSD.

So, there are going to be four symptom clusters and there are specific number of symptoms within each cluster. And if you achieve all of that and hit all of those criteria then you could qualify for PTSD after a month post-exposure. Now, the other piece that’s the same for both of them is that the symptoms need to be impacting an important part of your life. So whether it’s a social piece of your life, or if you’re in school and it’s impacting you academically, or if you are at work and it’s impacting your ability to function at work those are all important areas and aspects of our life. So, if these symptoms are getting in the way of that.

Now, I’m happy to go on through all of these symptoms just so that we can make sure that we are all talking about the same thing. And I think further on in our discussion we’ll probably reference back to them. So, I figure if I take some time and talk about each one of these symptom clusters that maybe it’ll help us so that we can really think about how trauma may impact us in different ways. And again, that first piece is always around that exposure, right? So, going back to that definition of trauma according to the APA, that exposure piece to death, or the threat of death, serious injury, or violence, or threat of serious injury, or violence. And in addition to that there is that piece of learning about someone close to us who has potentially experienced trauma which can be really, really hard.

Now, in addition to that piece there is also, again, I think I mentioned it earlier with the DSM-5 how they added that piece around vicarious trauma, that piece around people who are in the line of work where they hear about these traumatic experiences over, and over, and over. And how sometimes after that has been the case for so long that people who are in this line of work may start to also show signs and symptoms of PTSD, okay? So those are the exposure pieces and that’s criteria one.

Now, we get into the symptom pieces. So, the first cluster of symptoms I call the intrusive symptoms. And so, with the intrusive symptoms that can look like intrusive memories. So, when I say intrusive memories sometimes they’re like, I get confused, what are intrusive memories versus what are flashbacks? And intrusive memories are you might be doing, or trying to work, or sitting at your desk and reminders of that traumatic event just keep popping into your head. You’re like, can you please just stop for a second. And you keep trying to focus on what it is that you’re doing, and that memory keeps popping back into your head no matter how many times you try to try to change that.

So, the difference between the intrusive memories versus a flashback is that in a flashback you actually feel like you’re re-experiencing it again. You may lose sight of what’s around, you may lose sight of the fact that you’re sitting at your desk because you feel like you’re back in it. You might see the things that you were seeing when you were experiencing that traumatic event. You might hear and smell the things that you’re hearing and smelling when you experienced that traumatic event. And so that piece around losing sight of where you’re at, forgetting where you are in that moment that is what constitutes a flashback, right?

So, in addition to those intrusive symptoms there’s also dissociation or dissociative reactions, right? So, with dissociation I always give a little spiel when I do my PTSD group at the Hill Center. And I talk about how dissociation is when you feel disconnected from yourself. But there can be a whole spectrum of dissociative responses from mild dissociation where you feel that disconnection, you might feel like you’re going on autopilot a little bit. And you might get into your car drive somewhere and yet you have no idea how many red lights you hit, or how many stop signs, or any of the people who you saw that you’re diving past. And you still get there because you went on autopilot, you’re not really connected to the drive or seeing every single thing you are, but in your mind you’re not quite connected to it. In that moderate range of dissociation people start to lose some time, maybe even lose a little bit of memory, right?

So that piece around disconnection sometimes people will say I was sitting down at my couch, I think I was watching TV and all of a sudden it was three o’clock in the afternoon and I have no idea what happened, right? And then in that more intensive dissociation similar things can happen. And yet what can also happen is that really intensive amounts of time and memory can be lost. So, when we think about that dissociation piece we always talk about how originally when exposed to that first trauma our brain can protect ourselves in this way where this exposure might be so intensive. So hard to comprehend that it’s almost our brain’s way of protecting ourselves against how intensive that experience was.

So we disconnect from that so that almost people will say, well, I had to keep functioning, I had to keep doing what I needed to do so I just kind of went through the motions, and I just went to work the next day and I would just keep doing what I needed to do. And then they forget that piece that they were disconnected from themselves and may not really feel like they experienced it, or even processed through, or even connect to that experience at all.

When that happens at a really young age, or really intensively, or multiple times I don’t want to forget that piece around DID that can also happen which is dissociative identity disorder. And that’s that far end of dissociation where pieces, parts of people can feel like they actually split off related to the intensity, the event that was happening. And it might happen repeatedly and be so severe and persistent that parts of people might actually split off. So that’s that dissociation piece.

Also, within that intrusions is that response, that physiological response. So sometimes we will say, I feel like I’m having panic attacks all the time. And they don’t quite understand why or that there was maybe a cue that they had. Sometimes people will call it a trigger or an association. And they see something, or hear something, or smell something, or go near somewhere that reminds them of this trauma and it will quickly lead to this physiological response. So that’s the intrusion piece.

The second category of symptoms is around avoidance. And avoidance is such a huge piece of trauma because a lot of times trauma elicits so much fear. It can be so scary. Whether it’s scary because it feels so out of control or scary because there literally was a threat right in front of you. And so, in addition to that fear there’s also that emotion of shame that can so intensely fuel that avoidance.

So, when I think of avoidance I think of people, places, things, emotions, memories. I always tell people don’t forget to think of your five senses because our five senses can elicit so much of our memory. So, it could be just a small smell that reminds us of that. And all of a sudden full-blown panic attack and you can’t breathe. And you’re like, what just happened? How did that happen? And until you’re able to make that connection of, wow, okay, that smell or that visual cue right there can lead me to remember, or it’s associated with that trauma. Then all of a sudden that pieces, okay, now, I can start to make sense of that.

So, another category of symptoms is also around negative alterations. So, with negative alterations just feeling like your mood is low, feeling like you can only experience negative emotions and that it’s really hard to connect with those positive emotions. So, feeling like there’s no way I’ll ever experience joy or love, how would I ever do that? All I’m doing is sitting in this sadness or sitting in this fear, or shame, or guilt and feeling like that is just over encompassing every part of your being.

With the negative alterations a lot of times people will say that they lose interest in things that they once enjoyed. They’ll say that it’s really hard to remember things because their memory is that, it’s hard to focus and concentrate on things. Sometimes they’ll have this belief that start to take over. So, beliefs both about themselves and about the world that it’s just a scary place or it’s not a safe place.

Or they’ll start to really question themselves and live in a place where they start to blame themselves or even experience some unjustified guilt about what happened. Kind of replaying it over and over about if I only did this, or if only I tried this instead, or maybe if I didn’t do this. And hindsight is 20/20 but it’s so hard in those moments to know how are you going to respond? And it’s not so helpful to beat ourselves up after the fact, right?

So, another category of symptoms is also around alterations and arousal. So, this feeling of hypervigilance that might happen where you’re constantly scanning. Sometimes people will say to me I feel like I have a sixth sense. I just know what’s going to happen because they’re so aware of absolutely every single thing. They know every single person that’s in a room at any time and they can give you such a good description of them. They’re so on edge though and feeling like any little things. So, someone can go up to them and touch them on the shoulder and they’re through the roof. So that piece around exaggerated startle, right?

In addition to that there is sometimes reckless and impulsive behavior or self-destructive behavior that can happen. And that can be as a result of almost reenacting the trauma and trying to feel like, okay, if I do it this way, see I can have control over it. I’m in control of it this time. And reenacting it in that way to feel that sense of control or power over it. And then there’s that piece around sleep. So, with sleep, sleep can be so impacted by trauma. Sometimes with that avoidance piece can fill our schedules day in and day out so that we are busy all day long and then we exhaust ourselves until we fall asleep, and then it can subconsciously come out in our sleep or we might have nightmares and night terrors.

So one thing that I just thought of as I was talking a little bit about the avoidance that I want to just make sure I touch base on is that again that piece around avoidance and that trauma can look so many different ways. So, there are so many different ways that we can avoid. And I like to always just touch base on what are ways that people can avoid. So sometimes that’s literally physically avoiding everything, which means I will cut off all ties with all people because all people they’re just not safe. And so maybe it’s easier if I don’t put myself in that situation where I can be in harm’s way. And so, they’ll cut off relationships, they’ll start to isolate. So that’s that kind of physical isolation.

But I also mentioned that piece around, sometimes you fill yourself up with so many things to do and you think, well, look how productive I’m being. And it can be great and it can be really productive by over-scheduling yourself or overworking until all of a sudden it catches up to you and you realize but I haven’t actually taken time to pause and think about how I’m feeling or even to look at any of my emotions. Other ways that people avoid are by sometimes not wanting to feel. I don’t want to look at these emotions, I don’t want to feel. And they might turn to things like substances or they might turn to things like self-injurious behaviors, or they might turn to things like disordered eating patterns, because if they’re in a place where they’re not feeling in control, well maybe I can control what I take in and my diet or maybe I can control how much food I take, I eat. So those are our symptom categories. And that’s breaking down PTSD kind of in a quick nutshell for you.

Jenn: I know it’s just so hard because it’s so complex and you want to give so much time to everything. And at the same time, we’re like, oh my God, we only have an hour. How are we going to get through all of these conditions? But I think you’ve done, I mean, you’ve done such a good job of differentiating what these different categories look like based on conditions so that folks can feel more equipped to go in their doctor’s office and say, hey, this is what I’m feeling and actually actualize it because sometimes when you’re dealing with big emotions like this, and you’re dealing with these sensations it’s so hard to go to your doctor and make it into like qualitative information.

Patricia: Absolutely.

Jenn: So, we did have some folks ask about what is the difference between secondary and vicarious trauma? Can you explain a little more about that?

Patricia: Good question, yes. So, with vicarious trauma, actually, I’m going to go through four different layers in terms of that. So being a health care provider, or someone who hears about, or is exposed to details of trauma regularly we are so easily exposed to the idea of burnout. Anyone who is not feeling some semblance of burnout here in this pandemic right now, I don’t know how you do it. But burnout can be one of those things that’s actually, short-term. It’s thought of as short term where you take some time to rejuvenate and you can feel better, you notice a difference.

When it starts to be a little bit more long-term and you’re in this field of helping it can initially start off as compassion fatigue, right? And with compassion fatigue you start to feel those emotional and physical effects of that burnout, right? The burnout that lasts for a long time or burnout that feels like no matter what you just can’t make it go away even if you are taking time to take care of yourself. So that’s that piece between burnout and then when it starts to turn to compassion fatigue.

When we get into vicarious trauma. So, after you’ve been exposed for so many times and you’ve been thinking through it and doing this over a periods of time, when your world’s view starts to shift. when you start to notice, whoa, okay, I’m starting to notice that I work in a place with all women and a lot of times when there is a male, it’s like oh my God, there’s a male here. And when you start to notice, wow, not only do I notice that there’s a male here but I feel like all males are starting to be unsafe or that the world is starting to feel unsafe. That’s when you’re starting to get more into that vicarious trauma.

And then that piece around secondary traumatic stress. That’s when the provider who has been hearing all these stories over, and over, and over again starts to actually develop symptoms of PTSD. So that same symptom category that we just went through, all of those four categories, when people start to experience that based on hearing all these stories over and over in combination with that burnout piece, with this compassion fatigue, with that vicarious trauma where your worldview starts to change. And now in addition to that all these other symptoms.

Jenn: So, we also had some folks asking about clarifying the differences between symptoms of PTSD and CPTSD if there are any differences?

Patricia: Okay.

Jenn: I know, this is the problem with having a session called The Truth About Trauma. And then only giving us 60 minutes. So, I’m sorry about that.

Patricia: So okay, with complex PTSD that is a different sort of thing where complex PTSD I view it more as a developmental trauma. So when things happen when you are younger, when you’re exposed to trauma when your brain is still in a place where it’s developing, when you’re in a place where not only is your brain developing but your first exposure to relationships, your first exposure to emotions, all of these things where you’re just trying to learn about the world and about yourself. And there’s that trauma piece that’s also there.

So that can impact all of those basic things that you learn when you’re young and your first exposure to all of those things when you learn when you’re young. And thinking about how that can impact relationships and attachments, especially if that trauma came from people who are supposed to be providing care to you. That’s kind of a very simplified form of differentiating between complex PTSD and PTSD.

And yet recognizing that when traumas happen if you are say, for example an adult, and you have experiencing trauma or a recent trauma and you have a history of traumatic experiences those historical traumas that you have that already happened when you were younger, those will pop up again.

So, say for example, someone just went through a scary incident where they felt like their life was in danger. If they had an incident of that when they were much younger, when they’re trying to understand what’s happening to them currently, sometimes they find themselves back in the past or where some of those past experiences come rushing into their head where it’s really hard for them to distinguish what’s happening to me right now? What am I experiencing right here right now from this current trauma versus what might be kind of ghost from my past and things that maybe I haven’t had a chance to really process through yet.

Jenn: So, in theory then are traumatic events that are experienced at a young age more harmful?

Patricia: They can show up in different ways and they can. So, if those traumas are not treated or if they’re not brought into treatment where a person can understand how those traumas may be impacting them they can develop into different patterns of behavior. And so, it might be harder when someone’s seeking out treatment at an older age to unpack and figure out, okay, why is it that you turn to alcohol? Or why is it that you turn to disordered eating patterns for this? Or where does this stem from? And it might stem from a place of trauma which is why I’m going to give my quick spiel about, and to all of our providers who are out there who are listening about the importance of trauma-informed care and holding onto the piece that trauma is so prevalent. So, so prevalent.

There is a study or a paper that was put out there by the International Journal of Nursing back in 2014 that showed that 90%, nine out of 10 people who seek out mental health care have experienced a trauma. When the number is that high it is so important for all of us to remember to use these ideas of trauma-informed care of recognizing how prevalent it is and to make sure to address it. Address it in a way where even if you’re not a trauma therapist that at least you’re recognizing, okay, is there a piece of that trauma fits in here?

Jenn: So, if I’m trying to find a specialist who has that piece of trauma-informed care education or background how do I get started? Is there a database? Is there a specific question I should ask?

Patricia: So that’s a great question. And I think there’s a lot of times now some of those databases where you can look up and Google online. You can specifically look for trauma-focused, trauma-informed providers. Also, I think it’s important to look at places that are trauma-focused, right? So really thinking about and asking people when interviewing. So, I always tell people when looking for a therapist, when looking for a provider, it’s always an interview.

So, you’re interviewing them to see if they’re a good fit for you. They’re interviewing you to see that this is a good match. And so, when doing that interviewing process asking, what is your experience with trauma? What’s your experience with being trauma-informed? Are you trauma-focused? Are you trained in specific types of trauma-focused therapies?

Jenn: So, I’ve told folks before that trying to find a therapist to me it’s like analogous to dating because it’s like you need to have a few sessions to make sure they’re a good fit. If not just let it fall apart organically but.

Patricia: Absolutely, yeah. I always say it’s interviewing. It’s an interview process and it goes both ways. So, I never want people to feel like they’re the one that’s constantly being interviewed because it’s totally, it’s a two-way street.

Jenn: Exactly, so we had someone write in saying that they recently realized their childhood was full of traumatic events, but they’re now a grown adult. So how as a grown-up do they know if they should see a specialist about the physical and psychological trauma that they had endured?

Patricia: So that’s a great question. And one of the things that I always think about is that there’s never any harm in being able to reach out and find some support or even just a safe space to explore. If you’re experiencing symptoms that you’re noticing, when hearing about PTSD symptoms if you’re noticing wow, a lot of those apply to me then I would encourage you to seek out that help earlier.

If you’re noticing, okay, well, maybe I just want a safe space where I can just understand and be curious about this a little bit more and think about, wow, how might that childhood trauma be impacting me now? Might I feel like, okay even making some of these connections that I could bring a better me to my life then that’s a wonderful thing.

And so, we always talk about trauma-focused care occurring in stages. And so ,where I work at the Hill Center we’re a stage one trauma program where we talk just about safety, stabilization of symptoms and psychoeducation about trauma. And by staying there and really thinking about, wow, how has this trauma impacted my life? How is this manifesting into specific behaviors and patterns for me? And what do I want to change so that I can live a more fulfilling life, so that I can feel like I bring a better me to my life.

And then from there people can then decide, do I want to process through my trauma more? And there are very specific trauma-focused therapies from there that are very well-researched and where you can then go from there. But the idea is just being able to explore it a little bit more, being open to explore. Hearing that someone was bringing that up and just saying, maybe I want to explore that more, that’s fantastic.

Jenn: So, does the impact of trauma ever go away on its own or does it always require some sort of medical intervention to overcome?

Patricia: What a great question. So, what’s important to remember is that yes we’re talking about the symptoms and the diagnosis of PTSD or acute stress disorder and not everyone goes on to develop those diagnoses or even some of the other diagnoses that we had been talking about. Recognizing that avoidance piece where sometimes people will avoid by engaging in substance use, or disordered eating patterns, or even just be diagnosed with depression or anxiety.

So, it’s not always going to happen where you develop PTSD or acute stress disorder. And the important thing to remember is how to stay connected to people, how to recognize and be aware of the signs and symptoms, to notice do I maybe need a little bit more support? Do I need to explore more? Do I need to get help at this point? Because if you’re aware of that then that’s helpful to kind of guide you towards, okay, maybe all I need is to just have a safe space and talk to a therapist, whether they’re trauma-focused or not. Just a safe space to kind of understand my symptoms a little bit better.

And sometimes it’s a matter of, okay, it’s not always going to turn into all of these symptoms, right? And that’s also a wonderful thing because we are resilient as people and we are social as people. And so being able to stay connected with people even at a time when our fear, and avoidance, and shame might be so intensive is an important thing.

Jenn: So how would you recommend that providers go about adding trauma training to their skillset?

Patricia: There are so many trainings out there, lots and lots of trainings. And I think one of the first things to start off with is that piece around trauma-informed care. That piece around just being aware of how prevalent trauma is and thinking about how do I resist retraumatization. That is one of the biggest tenants of trauma-informed care.

One is providing a safe space for a person to be able to recover, right, for a person to heal. And by creating that safe space for them you’re also going to help to empower them. Empower them in making choices for themselves, empower them in terms of taking control over pieces of their life that might feel out of their control. And the biggest important piece of that is resisting retraumatization.

Jenn: So, with providers treating everybody, should they be digging into adverse childhood experiences or is this something that the patient should be bringing up on their own?

Patricia: That’s a great question too. So, it’s important to be aware of them. And there’s a way to be able to ask people about things without digging. So being able to just ask people about or doing a basic trauma screen of asking yes or no questions and letting them know before you go into a trauma screen. So, trauma’s a really important thing. And I just want to make sure that we are thorough in terms of getting a really good history from you of different things that might be impacting your current mental state.

So, asking some basic questions about whether or not people have been in a situation where they felt like they were physically threatened, where they felt like they were a victim of bullying. Whether they experienced a medical trauma, whether they experienced a situation where their home was invaded, where they felt violated in some way whether it’s physically, sexually, emotionally.

Whether they felt like their needs were met when they were younger, both emotionally but also just in terms of having food on the table, having a roof over their head. And you can ask those questions in that way without eliciting more. And you can even say, so I’m going to ask you some questions and I’m going to welcome you to share what you feel comfortable sharing.

But also, it’s important for the provider to be able to recognize at what point do they notice if the person sitting in front of them might be too activated, might be starting to tell this story in a very robotic way. And at that point a provider can always pause and say so I’m noticing that we’re not quite connected in that same way. Is this eliciting a lot for you? Okay, so we don’t actually have to continue with that.

And that’s an okay thing because I think you have some information already and enough to know, okay, there’s likely a traumatic piece to this and you don’t have to go further into it. And if you don’t feel comfortable providing trauma-focused care or you’re not trained to do trauma-focused care that’s also okay. I think it’s really important to recognize your own limitations, what you feel comfortable doing so that you can help the person in front of you to get the best care that they need.

Jenn: So, are there specific types of therapies that are done to help reduce or remove the impact of triggers?

Patricia: Yes, absolutely. So that would go a little bit more into that stage two treatment. So, I know that we talked a lot about stage one treatment and just better understanding the symptoms. And in that stage when we also talk about ways to just manage symptoms. So, within phase one or stage one of PTSD treatment you can actually do a lot in terms of implementing skills, right? So, at the Hill Center, what we do is we do a lot of DBT, trauma-informed DBT is what we call it.

And that way we can help people to understand some of those symptoms and help them to find ways to initiate skills to bring some of that down. So, distress tolerance, emotion regulation, interpersonal effectiveness, mindfulness and just grounding, right? Using your five senses to help you to really just focus in on the right here right now. Recognizing if some of your past may be coming in which may be the trauma piece or even if it elicits so much anxiety that you’re 10 steps into the future how to bring it right back to the here and now.

But there’s also stage two trauma-focused therapies. And so, three of the most well-known, well-researched ones are EMDR, so that’s eye movement desensitization and reprocessing, there’s PE which is prolonged exposure, and then there is CPT which is cognitive processing therapy. And those three have been really well-researched, really well studied and are ways that people can go about to challenge some of the cognition. So that’s more for CPT of challenging some of those cognitions that might be there, for P exposure so kind of exactly how it sounds where you probably may have heard it from OCD treatment but exposure piece, right? And over time desensitizing to that exposure, to those cues that might elicit such a physiological response for you.

And then EMDR is really about kind of taking that how our information, how is processed and using these bilateral movements, whether it’s tapping or eye movements to reprocess that information, to desensitize at first, and then reprocess to create some more positive statements that we say to ourselves to replace those negative ones. These are great questions.

Jenn: I know. And we have so many. I’m trying to get through as many as I can, I promise. Someone asked, and I am genuinely curious at what age can trauma impact you as an adult?

Patricia: Any age. Trauma is ubiquitous, trauma is everywhere, trauma can impact you at any time. No one is immune from trauma. So, we see people here at the Hill Center from when they turn 18, because we’re an adult program, all the way up through all the ages. I mean, there is no one who is not impacted by COVID and loss and all of these things that we are still getting used to. So, trauma can impact you at any age, at any stage of your life. Great question.

Jenn: So, somebody close to me has insinuated that they experienced trauma at one point that they really haven’t gone into a lot of detail. How can I talk to them about it and suggest gently that maybe they should seek help? Do I even try talking to them? ‘Cause I mean, I’m not a therapist and I don’t want to make it worse.

Patricia: Yeah, we hear that all the time from family members. So that’s such an important piece. And recognizing, yeah, so if I’m not a therapist or I’m not someone who feels comfortable with this again recognizing your limitations. However, the importance of being there for them, being a support to someone when they’re experiencing so much fear and shame is so important.

So even just reflecting for that moment quickly about COVID. How nice it was that I saw people who were impacted by COVID where people would say, okay, you may not want to talk to me, you may not want to hear anything, you may not want to get out of bed but what do you need right now? I’m going to the grocery store and on my way home I’m going to be able to drop off whatever it is that you need for you.

So, either give me a grocery list or I will do my best to guess and here’s something that I’m going to drop off at your house. Or something like I’m concerned about you but I want to be here for you. So, let’s focus on the right here right now and just day by day, so can I just give you a call? Can I give you a text? And again, that piece around that feeling of control was likely taken from them?

So, the idea is not to force someone to talk about things if they’re not ready to. And how to encourage, how to be curious, how to just sit with them sometimes. I think about seeing Winnie the Pooh and Piglet in a meme that I once saw about them sitting together and Piglet saying I had a tough day. And Winnie the Pooh saying, well, I can just sit here with you, and sit here and hear about your tough day with you, right? So how to just be that support for someone, how to just be there for them when they’re in a place where they’re probably wanting to isolate.

When they’re so terrified of what happened to them, terrified of maybe judgment that they’re going to receive from other people. Terrified of feeling so alone with what they just experienced and terrified to even talk about it because it could be scary to even think about it. So, if you could just be there with them, if you could offer ways, even offering suggestions of, hey, I’m going to check in with you on Tuesday. Would you rather me check in by text? Do you want to FaceTime? Do you want to Zoom? I’ll figure out or we can call, but I just want to see how you’re at, what you’re doing, how you’re feeling.

And you don’t have to go into it. And even saying to them, you don’t have to go into it. I know that you’ve been through a lot but I am here if you do. And if it starts to feel like it’s beyond what I know how to help you with here’s some resources that I found. Here are some ways that we can together look through some resources. Or together just research something to see okay, let’s see if we can find you a therapist, let’s see if we can find you a support group.

Jenn: I think it’s been really nice too that one of the things about COVID, I can’t believe I’m saying there’s something nice about COVID, is that folks have been way better at checking in on the people that they care about. And when somebody responds with, oh, I’m fine, you feel more inclined to be like are you actually okay? And it’s helping people talk more about their mental health and further destigmatize that conversation. I think it’s just, we can show up for the people we care about in just such a nice way that I feel like prior we hadn’t been.

Patricia: Absolutely, I think that’s such a great point in that remembering that it doesn’t matter who it is, but I think right now everyone needs to feel connected in some way or another. And so, it’s those friends or those people in your lives who are least connected who need that call or who need that text just to know that someone’s thinking about them.

Jenn: I can’t believe how well you just teed me up for my next question. So, the question is what’s the best thing to do to be supportive if someone is going through a traumatic episode and it’s putting them in a consistently low mood that they can’t seem to get out of?

Patricia: Yeah, so again, that piece around just being there with them. Being their Piglet for them, right? So how to just kind of recognize, okay, yeah, this can take a toll and sometimes it can take time. But it’s not just about always weathering the storm and waiting for time to pass because that doesn’t always happen.

And so, it’s also okay to recognize you know what I think it’s time and I’m really concerned. How do we help you to get connected, to get connected to more, what do you feel comfortable with? Right, and sometimes it’s, I can be there, I can be that support. And sometimes it flips into that, okay, we’re going on month six now where I’m really worried about you. And yes, this pandemic is continuing on, and on, and on. And yes, it might be related to that but there’s also help out there and you don’t have to do this alone.

Jenn: So, any tips on how to address trauma with friends and family that might not actually understand the major impact that trauma can have on us?

Patricia: Yeah, so that’s a tough one. And I actually, one of the things that happens a lot here is that people who come here ask, can we just sit and talk with my family so that they hear what I’m hearing? Because it makes so much more sense and it’s hard when they hear it from me but when they hear it from you it might make it a little different.

And so yes, there are so many resources out there in terms of being able to just break down what is trauma, right? How can it impact us? What can it look like? And sometimes they will say, wow, wait, that’s you in a nutshell. And they’re like and that’s the reason why I’m here and why I’m getting the help.

Jenn: So, do you have any advice about how to motivate somebody that has a history of trauma to become more active? There’s been light research that exercise could be part of a treatment plan. So maybe that’s a possibility?

Patricia: It is always a great thing to be able to go back to your basics, right? Even while people are engaging in trauma treatment we always remind everyone, get back to the basics in terms of how are you taking care of yourself whether it’s nutrition, exercise, we all need sunshine. There are so many things that we could be doing to take care of yourself. Making sure that you’re remembering your sleep routine because we need to promote sleep. Sleep impacts so many things that will help with your mood, that’ll help you to bring your best self even to treatment.

But yes, exercise has so many pieces to it that can really help us to feel better. And I want to recognize, how hard it can feel to engage in that, how hard it can feel to engage in self-care, how hard it can be to take that first step. And so not setting these huge goals for ourself of all right, so by the end of this pandemic I will be running a 5K. No more like, how do I even just start? What’s a baby step that feels okay? Can I get outside a little bit more now? Because the risk of COVID is a little less I can wear my mask. And the weather’s a little nicer that motivates me to get outside just a little bit.

And not that you have to go on a five-mile hike, but more of can I just start to be at one with nature a little bit. Can I just get outside and move my body a little bit and see how it goes? Let me be curious about that movement and see, okay, do I feel better? Kind of take a survey of yourself before, take a survey of yourself after. Did that help? Huh, okay, it did help a little bit just to be outside, get some fresh air. And can I build on that?

Jenn: It’s also really important to remember too that like exercise is a form of self-care. Self-care isn’t all face masks and bubble baths and like sumptuous dinners by candle light. It’s there’s self-care is subjective. So whatever works well for you that is your self-care, do that.

Patricia: Absolutely, I always include in self-care are you doing just taking tally on what’s happening, right? Being able to connect with yourself for even just 10 seconds that gives you such important information of, what am I bringing to this day? Sometimes I’ll encourage people to not just put in a routine before going to bed, but thinking about when you wake up in the morning, can you do a grounding skill just to kind of center yourself.

And then do a quick self-assessment, where am I at today? What am I bringing today? What am I bringing to this day? Because it’s a lot, especially if you didn’t have good sleep last night, or if your belly’s hurting, or if you’re experiencing pain. There’s so many things that can affect that. And so how to be able to just recognize there are so many different ways to take care of yourself.

Jenn: So, I know that we’ve only got a couple more minutes. And first of all, I want to thank you for your time because I know how valuable it is. But we’ve got like a sprinkling of questions so hopefully we can get through the rapid fire before I have to let you go. Does that work?

Patricia: Sounds good.

Jenn: Awesome. So, is it common for people with histories of trauma to experience panic attacks without environmental triggers?

Patricia: Absolutely. So, and you might not know what the trigger might be, right? I like to use the word association as opposed to necessarily trigger. But it can be hard to understand where it’s coming from, and it could even stem from an emotional reaction. You might feel a little sprinkling of fear and that could be enough to elicit that association with the trauma.

So sometimes it means taking a moment to just reflect to see is there a potential for some sort of association that happened? It could even be a physical reaction, right? So sometimes when people experience pain, or if someone gets a headache, or if someone has any other type of reaction in their body where like sometimes just a little thing and it might be hard to be able to initially identify what that is. But it’s worth it to be curious, it’s worth it to kind of take a moment to really think about was there maybe something else that was going on there?

Jenn: So, are night terrors based in trauma?

Patricia: They can be, yeah. So, one of the questions that I usually ask people about when we’re going through symptoms as nightmares, night terrors, right? And the difference between the nightmares and night terrors is that sometimes when people experience night terrors they wake up and they still feel like they’re in it. They have no concept of where they might be.

And so, with sleep hygiene we always talk about not only that routine before bed, but also having a grounding tool kit right next to your bedside. So that when you wake up if you are not oriented how to bring yourself to that present moment first before trying to think about getting back to sleep. But it’s just a really ground to bring your distress level down and then to think about, okay, now, that I’m in a mindset where I can actually think about what just happened, how do I go about trying to go back to sleep now?

Jenn: Oh, I know I’ve already squeezed so much information out of you, but do you have time for two more questions?

Patricia: Go ahead, yeah.

Jenn: Perfect. And nobody saw me fist pump, but I’ll do it again. So, is cPTSD interconnected with personality disorders?

Patricia: There is a lot of overlap in terms of complex PTSD and borderline personality disorder. So yes, in the sense that the symptoms, the way that it presents can overlap so, so much that it actually takes time to be able to pull apart all of the pieces to say, wow, what is happening here? Right, that’s a great question. And I feel like I’ve seen a lot of talks too within McLean where they really break that down between the complex PTSD versus borderline personality disorder.

Jenn: Do you have any last words of wisdom about how to be gentle on ourselves or each other when we’re working through trauma?

Patricia: Exactly that. How I always remind people that this is a process, this is a journey to really just understand yourself better. And so, with that and recognizing that sometimes these symptoms have taken such a long time to develop into what they are, that in order to be able to start to pull that apart it’s also going to take time. And so, with that also requires some compassion for yourself and being gentle with yourself as you go through this learning process, go through this journey.

Jenn: Patricia, I cannot thank you enough for all of the information that you shared with all of us today. I knew going into this, that trauma was complex. I admittedly didn’t know how complex and I feel like you have basically handed me a giant flashlight to shine on all the corners of the condition. So, I just want to say thank you from the bottom of my heart. Thank you for your time, for your intellect and for your candidness.

So, this actually concludes our session. So, thank you to everybody who joined. And until next time, just be nice to each other, be nice to yourselves, and wash your hands. Thank you again, Patricia and thanks everyone.

Patricia: Thank you.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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