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0:00
CEUs are available at AllCEUs.com/Trauma-CEU hey there everybody and welcome to this presentation on trauma-informed cognitive behavioral therapy i'm your host dr donnelly snipes
0:13
in this video we're going to define trauma explore the prevalence of trauma identify the key elements of trauma-informed care and the principles of trauma-informed care we'll learn about the ongoing impact of trauma and discuss how trauma might contribute to the development of a variety of symptoms and how to address them from a cognitive behavioral standpoint
0:40
just because something does not meet the dsm criteria for acute stress disorder or post-traumatic stress disorder does not mean it wasn't traumatic and that's why a lot of clinicians have started embracing the term big t for ptsd worthy triggers and little t for other traumas that don't rise to that level but little t traumas are no less damaging for a lot of people than big t traumas and the analogy i make is a rock if you
1:15
take a rock and you smack it with a hammer and you chip a piece off that's like a big t trauma it changes the rock significantly and it happens all of a sudden little t traumas are like taking a rock and putting it in a river where the water rushes over it and erodes it over time does the rock change yes at least as much if not more than it did with that big t with that big hammer but
1:48
it's important to recognize and not minimize the impact that the erosion has on the rock and cptsd or little t traumas often have an eroding effect on people's lives so we're going to talk more about that but trauma itself is very simply something that overwhelms a person's capacity to cope removes a sense of safety and empowerment and affects the whole person physically when people experience trauma it triggers their stress response system their hpa
2:26
axis and until they feel safe again that hpa axis is going to stay activated when the hpa axis is activated it impairs immunity it impairs sleep it impairs a lot of biological functioning it alters the gut microbiome there's a whole host of ways that trauma impacts the person physically emotionally trauma impacts how a person feels they can feel guilty they can feel terrified they can feel depressed they can feel angry they can grieve they can feel all of the above cognitively
3:06
after we experience a trauma it impacts how we perceive others how we perceive the world it impacts our expectations so it changes our cognitions and potentially our perceptions
3:21
environmentally after people experience trauma again especially until they feel safe again they may feel unsafe in a lot more environments environmentally triggers sights sounds smells that are associated with the trauma are now going to trigger a traumatic memory so the environment has changed and sets instead of being completely benign now it is more fraught with potholes so to speak and relationally or interpersonally trauma affects people if it is a
4:05
trauma that is um induced by another person then it may impact how people feel about others it may impact how they feel about their ability to trust others it may impact how they feel about their ability to trust their own judgment if it is a natural disaster for example it may impact how people feel about others based on how they react in the aftermath of the trauma
4:38
trauma can occur at any age or developmental stage people may experience the traumatic event directly they're there they experience it it happened to them they may witness it or they may even hear about an event that affects somebody that is that they know that's very close to them
4:57
when we hear about something that a loved one experienced our empathy can sometimes put us into that situation with them mentally so we can become equally or similarly traumatized
5:16
it's not just the event itself that determines whether something is traumatic but the individual's experience of the event people can experience traumas and not develop ptsd or cptsd traumatic injury refers to ongoing issues associated with the trauma if people experience a trauma and receive sufficient support and love and are quickly returned to a place where they feel safe and empowered that is going to be very different than if they didn't receive those things
5:58
what's the prevalence of trauma 61 of men and 51 percent of women in the general population have experienced trauma and i would say well i know that that is an older statistic over the past five years there have been a lot of widespread traumas so i would guess that the number is significantly higher than that but we don't have data um from 2020 and forward quite yet
6:29
25 of school-age children have experienced trauma 96 percent of female offenders so people who are incarcerated 75 to 93 percent of youth and juvenile justice depending on which study you look at 93 percent of homeless mothers and 83 percent of homeless children have experienced trauma 93 of adolescents in psych hospitals and 75 of people in addictions treatment and 81 to 93 of veterans now you may be thinking to yourself for some of these how can it be less than 100
7:11
these this data is compiled based on giving people surveys about whether they perceive that they have been exposed to trauma so what is traumatic for one person may not be perceived as traumatic for another person and so it is important to recognize that there's a lot of variability in the numbers about the prevalence of trauma but even with these numbers where we're just taking people's self-reported trauma that is a lot 83 93 percent again we recognize that a lot of people
7:55
who experience trauma have the support they need to cope with it so it doesn't lead to traumatic injury but unfortunately i'm going to go out on a limb and say the majority of people that we see in mental health or behavioral health clinics and even in hospitals like physical health hospitals may have not had that support and may have experienced traumatic injury key elements of trauma-informed care realizing the prevalence of trauma
8:31
recognizing how it affects individuals and putting this knowledge into practice traumatic experiences trigger the stress response or the hpa axis which increases awareness and encoding of sensory input as well as physical sensations and thoughts into a memory van der kulk often says that trauma is experienced um as a sensation not as a memory in a lot of people so some people may not have a full clear memory of what happened but
9:08
when they're exposed to particular triggers they have this feeling in their body that is causes them distress we do want to recognize this but it's also important to recognize that when people are experiencing trauma when their hpax axis is activated when they're under significant stress their brain automatically becomes hyper aware of the people and the stimuli in the environment and it encodes all this stuff in order to protect itself so the next time that it's exposed to any
9:46
of those stimuli it may trigger a trauma related response and that is really important to remember
9:57
when all of these um sensations and memories and anything else are encoded
10:06
it becomes what i'll call a memory and that memory either forms a schema maybe a person's never experienced anything like it before so it's like okay when i write on subways this is what i need to remember or is added to a schema now remember schemas are your brain shortcut it's your brain's way of helping you anticipate what to expect stop lights is the schema that i usually use if you've been driving for any point of time in any length of time you know that when you come to
10:41
up to a stop light if it's yellow it's going to turn red you don't have to think about that you have schema about stop lights so if you pull up to a stop light and it's yellow and then it turns green or goes off completely then all of a sudden you're jarred out of your autopilot because that schema doesn't work anymore and you're having to engage your executive control network
11:08
triggers which can be in the form of sights smells sounds sensations that are associated with that event can activate the schema and associated perceptions feelings behaviors and cognitions and it can be a relatively benign trigger for example someone who was in a car accident on the interstate may have encoded the smell of gasoline or the sound of ambulances in their trauma memory so now whenever they hear an ambulance or smell gasoline it triggers trauma responses in them it
11:47
may not be a full-blown flashback but they may get that sensation or perception of or feeling unsafe
11:59
in terms of trauma-informed cognitive behavioral therapy it's vital that we recognize that many psychological cognitive behavioral symptoms originate from adapting to the traumatic experience so we want to get curious about people's thoughts and experiences
12:20
these traumatic experiences influence how people respond to the environment relationships as well as interventions that we may propose and treatment services if people feel remember trauma strips away a person's sense of safety and empowerment so if they come into counseling and we are too directive or they perceive that we're invalidating then that is going to again put them in a position where they may feel unsafe and disempowered and caused them to reject treatment services
12:56
or not respond well to interventions or not respond as we expected to interventions
13:03
traumatic experiences also shape the assumptions that people make about their world whether they view others as trustworthy and safe or not how they view the agency that you might work for or the system and their sense of safety in general in the world people aside do they feel like it's safe to leave their house it shapes their assumptions about their future whether they can have hope or not or whether they fear or for a foreshortened future and it shapes
13:40
their assumptions about themselves whether they're resilient and capable whether they're lovable or competent in living their life and regulating their emotions and keeping themselves safe
13:56
so in terms of trauma-informed cognitive behavioral therapy it's important it's vital to not invalidate a person's experience what they perceived six days ago six years ago when the trauma was going on was how they perceived it in that context at that point in time now in this context at this point in time maybe they can look back and get a different perspective but at that point at that in that context at that point in time they were
14:33
terrified and it's important that we don't take that away from them it's important that we help them recognize the function of those feelings and those perceptions at that point in time but i encourage you from a cognitive behavioral standpoint and a lot of times when we say cognitive behavioral people think cognitive irrational thoughts cognitive distortions cognitive restructuring well that's all wonderful because cognitions behaviors perceptions and
15:06
feelings all interact but it's important to remember that there's the behavioral component so from a cognitive behavioral standpoint in what ways do thoughts perceptions and feelings
15:24
impact agitation irritability and hostile behavior in what ways does anxiety impact people's behaviors functional or dysfunctional their other emotions their health their relationship
15:44
persistent and exaggerated negative beliefs or expectations about oneself others or the world you know that's one of those characteristics of ptsd but it makes sense from a cognitive standpoint when the person experienced that all of a sudden their expectations about themselves others of the world may have been turned on it's turned on their head and
16:11
if they have not re-established equilibrium if they have not re-established a sense of safety and empowerment then yeah they're continuing to feel unsafe they're going to continue to have these negative beliefs about what's going on so it's really important that we look at the beliefs
16:34
and help them identify how okay maybe in that situation those negative beliefs and expectations were spot on however in the present is are those beliefs true about everybody are or are those beliefs being over generalized so we might look at how those beliefs and expectations and sensations were spot-on accurate appropriate maybe even helpful in the moment during the trauma and whether that continues to be helpful in the present however it's not up to us as clinicians
17:19
to tell them what's right what's wrong what's appropriate what's helpful the person needs to evaluate it look at the facts for and against their beliefs and decide is this still helpful is this still accurate or not and then we can help them proceed and process from there and figure out all right based on your conclusions how can you become more empowered and feel safer
17:49
hyper vigilance totally makes sense when people don't feel safe you know again what we're talking about is trauma that has not fully been processed or integrated into the person's experience and so there's a part of them that continues to feel unsafe and when you feel unsafe you're more hyper vigilant when you're walking to your car at two o'clock in the morning by yourself
18:21
i don't care who you are you're probably going to be more alert more vigilant about what's going on you're going to be more hyper aware of the sounds the sights the smells around you because that is a situation in which you don't feel completely safe and again a person who's experienced trauma and hasn't fully integrated it is still often experiencing a lack of a sense of safety
18:53
hyperarousal is different than hypervigilance hypervigilance is noticing being hyper aware of everything hyperarousal is being easily startled and when you're hyper vigilant you're likely noticing more things you're likely feeling a little bit anxious a little bit unsafe which means it's easier that hpa access that stress response system is already primed so it's easier to startle somebody it's easier to prompt a stronger reaction in them
19:28
totally makes sense once they feel safe and empowered and their stress response can actually check out they can trigger the relaxation response more effectively then the hyperarousal will start to decrease but it's a process self-destructive behavior from a cognitive behavioral standpoint why might that develop in response to trauma into trauma-related symptoms sometimes self-destructive behavior develops because it helps the person not think about the trauma
20:07
sometimes self-destructive behavior develops because it gives the person a sense of control over their life over their destiny when they didn't have control during the trauma sometimes self-destructive behavior may develop in order to help a person feel something as opposed to numbing feelings or numbing thoughts or memories it's to help them feel something when people are persistently stressed when that hpa axis is on
20:38
for too long then the body naturally turns down the sensitivity of the stress response system so people not only are they not as startled as easily they feel flat most of the time but they also have difficulty with motivation and positive versions of excitement so sometimes self-destructive behavior or adrenaline-oriented behavior may be designed to help them feel something
21:10
social isolation again makes sense because after a trauma a lot of times
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other people are involved in a trauma whether they were involved in perpetrating the trauma or whether they were involved in failing to help the person feel safe and empowered after the trauma
21:36
people can develop negative feelings about others which may lead to social isolation likewise people may become socially isolated after trauma because they're so overwhelmed with their own feelings and emotions and fears and thoughts related to the trauma they're so exhausted they can't sleep that they don't have the energy for any more input they don't have the energy for anybody else's stuff so they as a protective mechanism they socially isolate
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and feelings of detachment or estrangement from others are common after a trauma because
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when somebody experiences trauma they're trying to get themselves safe and secure and sometimes it feels like nobody understands and or sometimes they just don't have the ability to
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or energy to connect with others at this point in time because they're so disconnected from themselves or so overwhelmed with themselves so all of these things as clinicians we need to get curious and say all right if this developed as the result of a trauma
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what function is it serving why did this develop in in response to this trauma how is this
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functioning in some way for the person in order to help us figure out what issues we still need to address like hyper vigilance and hyperarousal tell us that the person doesn't feel safe so how can we help them feel safe and and other behaviors may be designed to help them feel something or to numb feelings of depression anxiety guilt flashbacks etc so those are that's also something else we need to help them address in a
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way that is more meaningful and helpful to encourage them to move toward what they define as a rich and meaningful life
23:56
more trauma related symptoms avoiding reminders of the of the event do you really want to remember the worst day in your life or the worst months or weeks for people who are enduring something like bullying or domestic violence or even the death of a loved one by cancer remember i said trauma is not necessarily just big t trauma flashbacks are often your brain's way of saying hey i remember
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being in this situation or i still have this memory i still have this memo from this situation that nobody's filed yet and you need to figure out where to put it so we can stay safe and flashbacks
24:48
do serve a purpose so we we need to help people figure out the most helpful way to deal with those flashbacks and integrate them fear anxiety and mistrust we already talked about depression loss of interest or pleasure in activities and or a feeling of guilt are often common there can be guilt because they feel like they brought it on themselves they can there can be guilt for surviving there can be guilt for not being able to be as emotionally available to the people in their
25:27
lives now because of the trauma there's a lot of reasons guilt can happen hpa axis dysfunction is one of the main reasons for depression because it causes changes in neurochemicals but if a person experience trauma or traumas and they haven't made the connection between those experiences and their current state or their current behaviors they may feel very hopeless and helpless because they don't understand where it's coming from they don't understand
25:58
why they can't feel happy and that contributes to hopelessness and helplessness and depression
26:08
emotional numbness is also a common symptom of after trauma because the emotions that they that they felt were so overwhelming that they just put a barrier between themselves and those feelings so it's they feel anthodonic now some of that can be cognitive some of it can be neurochemical it's important to remember that during stress when that hpa axis is active it alters the
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proportion of the different neurochemicals and it's possible that after an extended period of time the person may not have the right balance of neurochemicals to feel particular emotions they may have they may be in this flat state that i mentioned earlier
27:05
sleep problems including insomnia or nightmares are also really common in trauma now not everybody remembers the content of their nightmares insomnia and and sleep problems are common is a common symptom of depression but it's also a common symptom of trauma so we need to look and say okay well maybe this person is presenting with depression and sleep problems is there also underlying trauma that is promoting that feeling of helplessness and hopelessness
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and keeping them from feeling safe enough to actually get good quality sleep
27:46
difficulty concentrating we need dopamine we need norepinephrine in order to concentrate when that hpa axis is overactive for too long our levels of dopamine and norepinephrine decrease additionally if people aren't sleeping well it's going to impair their comp concentration if people are hyper vigilant it's going to impair their concentration it's hard to focus on a spreadsheet when you don't feel safe and you're hyper vigilant to every flicker every move every sound that goes
28:21
by so we need to get i know i've said this 16 times already but we need to get curious and that is probably my battle cry for this entire presentation is instead of assuming that okay difficulty concentrating is a symptom of depression blah blah we need to say why is the person having difficulty concentrating what is causing that what is preventing
28:52
them from being able to cognitively focus is it a lack of a sense of safety is it low dopamine low nor norepinephrine is it depression or is it something else
29:04
chronic pain is also common in 15 to 35 percent of uh people with ptsd
29:19
so let's talk about a case example just to kind of put this into perspective sally um is nine years old in third grade her dad was never in the picture and her mom is addicted to painkillers and clinically depressed sally's mom will often disappear for days but even when she is physically present she's either out of it crying or angry
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so think about how does this represent a trauma is there a particular major trauma no but what we're seeing is adverse childhood experiences we're seeing a caregiver who is
30:01
emotionally unavailable a caregiver with an addiction or a mental health issue we're seeing abandonment dad completely abandoned mom will disappear for days on end so yeah sally a nine-year-old obviously is likely going to have a lack of a sense of safety she's kind of out there on her own and then when mom is present physically she's either stoned out of her mind or detoxing or experiencing cravings and she's crying or angry and irritable so from a
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nine-year-old's perspective it's really hard to predict what's going on there's a lot of chaos in the environment now initial relationships our initial secure attachments are supposed to help us develop emotional intelligence so we can label our emotions and
31:03
learn how to effectively modulate our emotions through the help of somebody who already knows how to label and modulate their emotions well sally ain't got this
31:17
so now sally's all grown up she is presenting with generalized anxiety disorder borderline personality persistent depressive disorder with intermittent major depressive episodes and dissociative disorder i figured i would just put as many diagnoses as possible in here so why generalized anxiety well think about it when sally was growing up she didn't have people providing nutrition for her she didn't even know if somebody was going to go to the grocery store for
31:49
she wasn't sure when or if mom was coming back every time mom would leave she wasn't sure when or if mom would wake up when mom was asleep she wasn't sure about how to get to school she wasn't sure if she was loved she wasn't sure about anything so as an adult she never learned
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how to cope with events that happen in life she didn't develop emotional intelligence and because her childhood was so chaotic all of those behaviors often and experiences often continue into adulthood if she is if she doesn't have somebody that's helping her with that which she doesn't right now borderline personality disorder is very common in people who experience adverse childhood experiences and childhood trauma now you could argue that it's cptsd but cptsd is
32:57
not an actual diagnosis in the dsm-5tr so we going with what we have borderline personality she vacillates between devaluation and idealization of people well that makes sense a nine-year-old thinks in dichotomous terms they love me they hate me sally personalizes
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everything a nine-year-old is very egocentric they have difficulty thinking abstractly about well maybe mom's acting this way because of the drugs or because of detox or because of something else it's about me as a nine-year-old it must it's directed towards me so it must be about me
33:44
so we have dichotomous thinking we have personalization we don't have anybody contradicting that for that nine-year-old and a lot of us don't aren't taught to go back and evaluate the ongoing effectiveness of our schema of our expectations so as sally grew up she maintained that dichotomous thinking she maintained that especially in terms of people and and mom seemed to be pretty um dichotomous herself and the personalization she
34:26
internalized a lot of things and that's how she learned to understand the world it's all my fault
34:33
the persistent depressive disorder so there for more than two years she's experienced symptoms of depression which occasionally rise to the level of meeting the criteria for major depressive episodes
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long-term hpa axis dysregulation as a result of trauma can lead to persistent depressive disorder or major depressive disorder so that makes sense in sally's environment that she grew up in she probably had a sense of helplessness and hopelessness her hpa axis was probably on all the time because she didn't feel safe
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so it would make sense that her neurotransmitters are out of whack right now as well as her
35:22
perceptions may be out of date remember back then she was thinking in ways that are appropriate and developmentally accurate for a nine-year-old now that she's an adult she has the ability to think more abstractly but she may not have considered those options and dissociative disorder
35:52
sally when she gets stressed sometimes checks out and that was a behavior that she developed when mom would go on her rages or when her anxiety would get too high when she was home alone she would just completely check out and quit feeling anything she would dissociate and she would have these periods of and still has these periods of time loss
36:22
so it's important to really look at these symptoms not look at the behavioral label but look at the symptoms for each disorder or condition and ask yourself how might each of these symptoms have developed as a result of the trauma or as a way to help sally survive when she was a child how do they make sense
36:51
physically sally as i mentioned likely has significant stress response hpa axis dysregulation when people experience trauma the schema become encoded and the connection between their amygdala which is where fear processing is and their default mode network or their autopilot becomes much much stronger so basically their fear network is constantly tapping on that autopilot going is there a problem look for threats is there a problem look for threats and
37:27
that connection becomes so strong that sometimes the executive control network or the wise mind as linehan calls it has a hard time taking over has a hard time turning off autopilot
37:42
the hpa axis dysregulation leads to a whole host of physical problems as i mentioned earlier and i do have another video on the youtube channel about the um neurobiological impact of trauma if you want to get into all the nitty-gritty but it's important to recognize that the structure of the brain actually changes it's not just people's thoughts but it's the structure of the brain and the balance of the neural chemicals actually change after extended exposure to
38:18
stress and or trauma which contribute to sleep disruption and exhaustion and sleep disruption and exhaustion cause that hpa axis to ramp up even more and try to dump
38:34
excitatory chemicals to help the person stay awake nutritionally people who've experienced trauma may self-soothe with food you know sally never learned healthy eating mom wasn't making breakfast or lunch so we're going to hypothesize that she grew up on a solid diet of fruity pebbles and peanut butter and jelly sandwiches pain and or muscle tension is common in people with anxiety when we are stressed our body says hey you need to stay primed you need to stay
39:10
alert so you can respond in the event of a threat which is why people's muscles stay sort of tensed so they're already coiled and ready to spring alcohol abuse sally didn't turn to painkillers because she saw what it did to her mom but alcohol was also very available in her household
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and even as a nine and ten year old she would turn to alcohol use in order to quell her anxiety when
39:48
mom was physically or emotionally absent and not suicidal self-injury is another physical symptom that she's displaying and sally engaged in non-suicidal self-injury in order to help stop the anxiety anxious thoughts in order to help stop the ruminations when
40:14
mom would disappear for days at a time sometimes she would engage in that so that
40:21
took her entire focus when she was engaging in that behavior she wasn't thinking about other things when she was engaging in that behavior she had control
40:33
affectively sally experiences a lot of emotional dysregulation or emotional ability well she never developed emotional intelligence she didn't have a secure attachment she didn't have anybody in her life that taught her how to identify and how to cope with them so it makes sense that
40:56
she's lacking the tools to regulate her emotions anyway but couple that with an hpa axis that's dysregulated so she goes from feeling flat to furious she goes from not feeling much to a tsunami of stress chemicals and it makes sense from a neurological biological
41:19
standpoint how she may emotionally dysregulate now cognitive behavioral interventions cognitively we can help her explore strategies for identifying and coping with emotions and coping with distress but behaviorally we also need to help her develop skills and tools in order to
41:45
help her brain and body recover help her brain and body not constantly be in a stressed state which includes good nutrition and sleep and relaxation exercises and vagus nerve stimulation depression and generalized anxiety especially and anxiety about abandonment are also very prevalent for her and exploring again the cognitions that are contributing to her feeling hopeless helpless or unsafe that's important and helping her identify cognitive ways and environmental ways
42:26
to deal with those but also helping her understand the importance of
42:36
behavioral interventions what physical things and what behaviors make her more vulnerable to depression and anxiety such as not getting enough sleep or over caffeinating or drinking alcohol so we need to help her explore how some of her behaviors
42:57
be contributing to or maintaining her unpleasant feelings as well as the cognitions
43:06
anger management difficulties goes along with that emotional dysregulation if you don't feel safe then you are already that hpa access is already on and primed and when something
43:24
intensifies that feeling of threat then you're going to respond either with anger or anxiety with fight or flee so her response being already already feeling unsafe already being primed when she feels unsafe she lashes out you know flat to furious she lashes out because there's a tsunami of stress chemicals and it's important to help her understand that that some of what's going on is a physiological response that can be corrected but not to assume that it's quote all in her head
44:04
to help her recognize that when she has that tsunami of cortisol and glutamate and fight-or-flight chemicals that it's important to use distress tolerance skills in order to ride the wave um until she can get into her wise mind and make more accurate judgments
44:37
sally also carries with her a lot of guilt because she still feels like it was her fault or some things were her fault in her childhood but she also recognizes that because of her depression her anxiety her trauma her everything that she's presenting with
44:59
she has harmed some of her relationships she has damaged some of her relationships and she holds guilt for that so we need to explore
45:11
what do you feel guilty about remember guilt is anger itself for mistakes that you made and how can you cope with that what cognitive strategies can you use and what do you need to do maybe the you need to make amends maybe you need to set better boundaries what is it that you need to do in order to behaviorally and cognitively in order to address that guilt
45:38
and grief not uncommon in people who have adverse childhood experiences she it grieves the lack of that ward and june cleaver leave it to beaver family she grieves not being able to have the childhood that she deserved helping her process her grief is going to be important helping her make a list and identify her losses and work through those is going to be important
46:10
cognitively sally feels hopeless and pessimistic a lot of her cognitions remember were all or none thinking and personalized and they've kind of gone unchecked over the years and so it will be important to use cognitive behavioral tools like we'll talk about in the next video like heartiness and creating a rich and meaningful life vision board to help her identify
46:41
what she might want to work towards inflexible thinking is very common uh in people with who've experienced trauma all or nothing thinking personalization and mind reading you know again as as a child she thought in all or none terms go back to piaget you'll find that that's pretty common in children um personalization egocentrism is very common in children so she still holds some of those in inflexible thinking patterns and then she developed this
47:19
cognitive distortion of mind reading in order to stay safe it was important in her
47:27
experience to anticipate to the best of her ability her mother's every need in order to prevent the rages so she learned the only way to stay safe is to try to
47:41
preemptively anticipate what people need without asking just you need to know and that creates a lot of stress because it is not possible to read people's minds she has difficulty with problem solving concentration and decision making largely due to her hpa axis dysregulation that's caused disruption in her dopamine and norepinephrine levels but also her hyper vigilance you know she still doesn't feel safe in relationships even in environments where she doesn't feel like she's
48:17
going to be physically harmed she is scanning for people who might get angry with her for some reason and or and she's constantly hyper vigilant to possibly making mistakes which may mean that she's not worthy or not lovable and then dissociation so we need to help sally figure out
48:39
you know understand how dissociation functioned for her but also help her figure out tools like narration and grounding strategies to help her manage her dissociation
48:53
interpersonally sally has low self-esteem and and an unstable sense of self well she was constantly getting raged on by her mother she
49:06
grew up in a very unstable environment she didn't have anybody that we know of cheering her on and saying you're awesome you're lovable so she grew up trying to get reinforcement trying to get approval from people by being whatever she thought they wanted her to be so she had this
49:29
ability which helped her survive but now she doesn't know who she is or what she likes because she was always trying to be what everybody else wanted her to be
49:40
she engages in frantic efforts to avoid real or imagined abandonment
49:46
when she gets into relationships she's still craving security like all of us do but she can't seem to create secure attachments and she's hyper vigilant to those cues in the environment or in the person that may have been put off by her mother or other people in past relationships that were preludes to abandonment we need to help her identify those triggers and process those learn from them learn how to develop secure attachments
50:24
unhealthy boundaries you know when you're trying to get approval and trying to get somebody to tell you that you're worthy of breathing the air and
50:34
trying to be whatever you think they want you to be a lot of times that also means having unhealthy boundaries and that can mean having really weak boundaries and letting them you know tell you what to think what to feel how to behave or very very rigid boundaries where you push people away and you can't um understand their perspective in sally's case her boundaries were very weak
51:03
defensive or passive communication she never learned how to assertively state her wants feelings and needs partly because she didn't know what they were but also partly because if she tried to it was met with a lot of anger and invalidation so
51:24
instead of stating her needs she just you know let it go she let it be quiet she was very passive in her communication other people may develop a defensive strategy where they have to be right they have to be in control and they can't hear other people's perspectives because that's how they developed um their their strategy to stay safe
51:51
and projection sally regularly projects onto other people what she expects based on past experiences and it's important to help sally start practicing tools like fact-based reasoning so she can look and say all right this is what i'm seeing but is this what's actually happening this is what i am perceiving but is this the whole picture what are the facts for and against my belief for and
52:24
against my perception in this context with this person at this time you know if my mom would have done that or if jim bob would have done that it may have meant something completely different but in this context with this person at this time what does this behavior mean so there's a lot of helping sally understand the importance of healing both her mind and her body in order to
52:56
feel safe and empowered it's important to help sally understand that her behaviors is not just changing the way she thinks but her behaviors that will nurture her physical health and help her create safer environments are also going to contribute to her recovery process
53:18
we need to help sally look at triggers um and and just kind of as a side note you know the smell of people in the past that traumatized her like cigarettes cologne or shampoo seeing somebody that looks like that person seeing happy families or likewise seeing families that look like hers feeling loved can trigger extreme fear hearing happy children playing or parents being neglectful in real life or even in the media like on tv or people using painkillers
53:54
though those are just some examples of triggers that we might want to help sally identify you know help her identify what triggers your anxiety what triggers your stress what triggers your sense of hopelessness and helplessness and just i give up and help her connect those triggers and understand why they trigger that feeling and then figure out how she's going to cope with those
54:26
trauma-informed cognitive behavioral therapy recognizes symptoms as a reaction to trauma it seeks to help people develop cognitive and behavioral strategies to feel safer and more empowered to address their symptoms it avoids invalidating people's experiences by trying to change their perception or memory of the event it helps them embrace the and when you were six or nine or whatever you experienced this and this is how you perceived it all right that six-year-old
54:59
you has that perception now the 26 year old you is there anything else you would add to that or are there alternate things to add to that picture we're not saying that the child's perception was wrong that was the child's perception and we need to process it and process how the child felt
55:19
and we need to also look at it with fresh eyes to see if holding on to that uh same belief system and those same schema in the present is going to continue to be effective in the next video on trauma-informed cognitive behavioral therapy techniques i will explore specific techniques and tools and how to use them in a way that resists re-traumatizing the individual
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