Cognitive Behavioral Interventions for PTSD

Cognitive Behavioral Interventions for PTSD



Dr. Dawn-Elise Snipes is a Licensed Professional Counselor and Qualified Clinical Supervisor. She received her PhD in Mental Health Counseling from the University of Florida in 2002. In addition to being a practicing clinician, she has provided training to counselors, social workers, nurses and case managers internationally since 2006 through AllCEUs.com 📢SUBSCRIBE and click the BELL to get notified when new videos are uploaded.
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Cognitive Behavioral Interventions for PTSD
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this episode was pre-recorded 
as part of a live continuing education webinar on demand CEUs are 
still available for this presentation   through all CEUs register at all 
CEUs comm slash counselor toolbox I'd like to welcome everybody today's presentation 
on cognitive behavioral interventions for post-traumatic stress disorder I am doctor 
Donnelly Snipes tonight we're going to review the symptoms of post-traumatic stress disorder real 
quick because most of you are probably already   familiar and we're gonna explore interventions in 
the following areas acceptance and behavioral or acceptance and commitment therapy dialectical 
behavior therapy cognitive processing therapy   and a few other cognitive behavioral techniques 
we're also going to look at behavioral techniques including exercise sleep nutrition and relaxation 
because cognitive behavioral is guess what a combination of both so we want to look at how this 
might happen but first we're gonna start after we review the symptoms for PTSD we're going to look 
at why cognitive behavioral therapy might be helpful and then we'll move into our interventions 
PTSD symptoms in the dsm-5 they added a fourth category of symptoms and so it's a little bit 
different than it was in the DSM 4 but not too much you have the category for re experiencing 
the traumatic event or intrusive symptoms that can be memories flashbacks nightmares feelings 
of distress when reminded or intense physical reactions to reminders PTSD symptoms of avoidance 
and an emotional numbing is another category where people have to have symptoms avoiding reminders of 
the trauma inability to remember important aspects of the trauma that one really frustrates a lot of 
people who have PTSD because they really want to remember what happened they want it to make sense 
loss of interest in activities and life in general feeling detached from others or emotionally 
numb and a sense of a limited future the third category is symptoms of increased arousal or 
hyper-vigilant difficulty falling or staying asleep irritability outbursts of anger difficulty 
concentrating hyper vigilance constantly being on sort of red alert and feeling jumpy and easily 
startled and the fourth category is negative alterations and cognitions and mood characterized 
by an inability to recall key features of the trauma overly negative thoughts or assumptions 
about oneself in the world exaggerated blame of oneself for whatever happened or blaming 
others for whatever happened negative effect decreased interest in activities and feelings of 
isolation like I said most of you are probably super familiar with all those but for the sake of 
you know being well-rounded I wanted to go over those symptoms really quick so let's talk about 
what happens in trauma though because in order to understand how we're going to treat it we need to 
understand kind of what's happening and how what we're doing is supposed to be affecting the person 
so when people are exposed to stressors the HPA axis I call it the threat response system and the 
amygdala are activated and they go ok there's a threat going on we need to release cortisol which 
we all know is the stress hormone which triggers the fight-or-flight response so we have excitation 
activation the person is ready to fight or flee they their heart rates faster they're breathing 
faster which is great in the short term because that helps us survive that is the awesome thing 
about the HPA axis it helps us survive sustained exposure to cortisol however has an adverse effect 
and impact on the hippocampus which is part of our brain that's responsible for learning and memory 
and it results in reduction of neurons and the dendrites don't branch as much so we don't have 
as much connectivity going on in there and you'll learn in a little while that reduced volume of 
the hippocampus is also a key feature in PTSD well what happens if memory and learning you know we're 
talking about cognitive behavioral therapy here   where we're helping people cognitively process 
well in order to cognitively process what's going on and address how they feel and what their thing 
you know memory and learnings kind of involved in that so if during trauma that area is kind of 
sucker-punched and it starts to lose volume and lose connectivity we can see where there might be 
problems doesn't mean that it's permanent you know we can help people develop reconnections think 
about people who have strokes or traumatic brain injury our brains are really awesome because 
they learn how to do workarounds it's like okay we've got a roadblock here where something 
happened let's branch and do something a little bit differently a blunted response to cortisol 
stimulation indicates pituitary receptors in the HPA axis have been down regulated in patients with 
PTSD so what that means is when cortisol is sent out for the fight-or-flight response people with 
PTSD at a certain point may not react with the same level of excitation as other people because 
their body has down regulated it's said you know what we can't we the body cannot deal with this 
much stress and this much excitation for this long we need to conserve energy for when there 
is you know a super duper threat out there so we're not gonna get quite as fired up now on the 
downside of that is when they do get triggered when there is a cortisol response it tends to be 
a dis regulation so the person gets really upset they go from you know not being too upset too 
terrified hypercortisolism and PTSD occurs due to increased negative feedback sensitivity of the 
HPA axis again it's being down regulated so not as much cortisol is being sent out the brain goes you 
know what I can't deal with all these stressors   right now I'm just I'm done I need to conserve 
energy because I can't win this fight whatever this fight is right now early adverse experiences 
including prenatal stress and stress throughout childhood has a profound and long-lasting effect 
on the development of neurobiological symptoms which may program subsequent stress reactivity and 
vulnerability to develop PTSD what we've learned so far is people who are experiencing stress 
activate their HPA axis in the face of chronic stress and chronic acts activation of that HPA 
axis cortisol levels go down the HPA axis there's primary and secondary hypercortisolism but the HPA 
axis basically down regulates what you're going to learn in a few minutes is that people who have 
hypercortisolism when they're exposed to a trauma so people who've had chronic stress or trauma in 
their past who are exposed to a new trauma are at a higher risk for the development of PTSD because 
of that hypercortisolism so one of the takeaways here is really important that we intervene early 
early intervention prevention to help people not experience chronic stress so if they're faced 
with the traumatic event of any sort it can be a car accident it could be a death of a family 
member whatever but if they're in a situation   where they're faced with the trauma that they're 
not experiencing hypercortisolism already because we know that that's a risk factor hypercortisolism 
plus trauma can can lead to PTSD so anyway the hippocampus which as I said earlier is involved 
in learning and memory and the prefrontal cortex which is where we do our impulse control and 
higher-order thought mediate the HPA axis so our memories in our hippocampus can say you know 
what I remember this it's really not that big of a deal chill out the prefrontal cortex on the 
other hand can look at it and objectively assess the situation ago you know what we're good right 
now we don't need to fight or flee you know we   can table that impulse for right now but review 
reduced volume of the hippocampus is a cardinal feature of PTSD again if that hippocampus is 
shrunk basically then we may not have learned as much or we may not have as much access to 
those memories you know I said the dendritic branching reduces so we may not have access to 
some of those memories in there interestingly hypercortisolism is thought to be an autoimmune 
response you know I said the body down regulates in response to chronic stress and another 
hypothesis not necessarily contradictory is that it's an autoimmune response to stress physical 
and psychological stress has been implicated in the development of autoimmune diseases so hypo 
cortisol ism is thought that it may occur after a prolonged period of hyperactivity of that HPA 
axis due to chronic stress again we need to get in there and help people figure out what's causing 
your stress so you are not chronically stressed that way you have the reserves to deal with trauma 
when unfortunately in a it inevitably happens the phenomenon of hypercortisolism has been reported 
not only for people with PTSD but also for healthy individuals living under conditions of chronic 
stress be it emotional or physical you don't have to have PTSD to have hypercortisolism 
but if you've got it you're at a higher risk glucocorticoids or cortisol interferes with the 
retrieval of traumatic memories an effect that may independently prevent or reduce symptoms of 
PTSD which makes sense if you don't have enough cortisol and you're exposed to a trauma then 
you're more likely to solidify those memories and experience PTSD if you've got enough cortisol 
then interestingly the brain says you know what you don't need to remember that right now for all 
intents and purposes during this stress situation and it actually prevents the formation of some 
of those traumatic memories hypercortisolism might be a risk factor for maladaptive stress 
responses and predispose people to future PTSD or stress-related bodily disorders including 
any of those autoimmune diseases that are out there and there's about 20 of them another 
interesting little fact simulation of a normal circadian rhythm or cortisol rhythm using eggs 
on eggs up externally introduced hydrocortisone is effective in the treatment of some symptoms 
of PTSD now this is not to say go out and start encouraging people to use steroids or something 
to increase their cortisone no no no no what it's interesting is that when the circadian rhythms 
are in balance the nor your normal cortisol goes up first thing in the morning that's why you 
wake up and get out of bed theoretically and   it gradually decreases during the day and it's at 
its lowest point when it's time to go to bed with people that have hypercortisolism that cortisol 
may never go up so it's hard for them to get out of bed they may feel kind of depressed withdrawn 
negative you know one of those symptoms of PTSD poor neurochemical features of PTSD and you all 
know that I am a huge fan of neuro chemistry regulation of dopamine norepinephrine serotonin 
and opioid neurotransmitters is all dysregulated each of those neurotransmitters or receptors 
for those neurotransmitters is found in brain circuits that regulate and integrate stress and 
fear responses well hello there's some interesting stuff there now one thing I do want to point 
out is that dopamine most people think about dopamine is our pleasure chemical and that's kind 
of a misnomer dopamine is actually our motivation chemical it's our go after that and get it again 
chemical our endogenous opioids are the ones that are more the pleasure chemical so when dopamine 
goes up Oh opioids also tend to go up mm-hmm so dopamine is your seek neurochemical it's the one 
that's going to give you the drive to do things which is another one of the reasons when we see 
people who take atypical antipsychotics they tend to be sleepy and not have as much motivation if 
their dopamine system is inadequate a cardinal feature of patients with PTSD is sustained 
hyperactivity of the autonomic nervous system   as evidenced by elevations and heart rate blood 
pressure and other psychophysiological measures we all know what panic looks like patients with 
PTSD exhibit increased heart rate blood pressure and norepinephrine responses so stress response 
increased HPA axis in response to traumatic reminders you don't have to be in that situation 
again anything that reminds the person of the trauma can trigger to a greater or lesser degree 
their HPA axis which again tells you that you're you've got somebody with PTSD who's going to 
have a more sustained HPA axis activation as they're exposed to various triggers and it can be 
anything from commercials on TV to smells to sites to places to people whatever and this is where 
cognitive behavioral comes in we need to help them start identifying some of those traumatic 
reminders and figuring out better ways to cope with them so it doesn't trigger that HPA axis 
response chronic exposure to stressors induce induces upregulation of 5-ht – which is one of 
the serotonin receptors and down regulation of 5ht 1a now the takeaway from this if you don't 
want to get into all the neurochemical stuff 5-ht 1a is the one that is usually implicated 
or talked about in terms of depression and anxiety and that's where your SSRIs generally 
target is that 5-ht 1a receptor the 5-ht 2 axis is actually more responsible for anxiety appetite 
cardiovascular function GI motility alertness and vasoconstriction well all of those in HPA axis 
activation when there is more of the serotonin all of those tend to be affected people get 
more anxious their heart goes faster their GI motility increases they become more alert hyper 
vigilant so there's a lot of stuff that we see that makes sense 5ht transmission may contribute 
to symptoms of PTSD including hyper vigilance increased startle impulsivity and intrusive memory 
because that 5-ht too is upregulated and remember 5-ht any of those are your serotonin receptors 
so increased levels of sera certain serotonin receptors can be responsible for a lot of the 
symptoms we see in PTSD to kind of summarize hypercortisolism is a key feature in PTSD it 
probably results from an autoimmune reaction autoimmune reactions are triggered or worsened 
by stress so people with PTSD may have excess dopamine norepinephrine and insufficient serotonin 
at the h1 receptor so we want to increase that five ht1 a receptor serotonin so cognitive 
behavioral treatment goals would be aimed at reducing physical and psychological stress 
including improving nutrition so the body has the building blocks to make the neurotransmitters 
it needs reducing stimulant and exposure improving sleep and addressing cognitive issues that 
maintain the stress response okay so now we're getting into the good stuff there behavioral 
interventions sleep when you are sleep-deprived your body perceives that as a stressor it says 
I'm tired that means I'm not as alert as I need to be and so I need cortisol to help keep me awake 
and alert if I can't go to sleep so when we are overtired our HPA axis or our cortisol levels tend 
to be higher that's not something we want people with PTSD tend to have very poor sleep insomnia 
you know or difficulty sleeping one of the key interventions they found is to work with people 
to help them improve their sleep and that'll help reduce some of their HPA axis reactivity think 
about when you're sleep-deprived does the world seem a little bit more difficult to deal with I 
know for me it does I'm just like really I can't take one more thing maybe that's just me but there 
are a lot of people who experience stressors more intensely when they are sleep-deprived think about 
if you've ever had children you know when they first come from from come home from the hospital 
and for the first yeah three six months they're not sleeping through the night which means you're 
not sleeping through the night and you know it gets a little bit challenging sometimes sleep 
is really important have people examine their sleep hygiene create a sleep routine on our You 
Tube channel there are a couple of videos that go in-depth on helping people improve their sleep 
nutrition is another one and again on the YouTube channel there are or on the podcast there are 
other episodes that cover nutrition for mental health but suffice it to say that your body in 
order to make serotonin norepinephrine dopamine gaba all of those neurotransmitters it has to have 
proteins it but in order to make those proteins into the neurotransmitters it also has to have a 
certain amount of various vitamins and minerals from calcium and folate to iron and magnesium 
and yada yada a good balanced diet is essential to make sure that people are actually able to 
create the neurotransmitters they need to feel balanced we need to help them stay hydrated 
for cellular function if you think about how everything communicates in our brain and our body 
it communicates through chemical signals and these chemical signals require fluid you know as weidy 
hydration is so challenging we need to make sure that people stay hydrated that's not going to 
be the be-all end-all but it's another one of   those goals that we can set for people help 
them exercise for oxygenation and to increase in their serotonin they've done study after 
study after study that has shown that exercise can help people reduce muscular stress you know 
we store stress in our back and everything else when we exercise it tends to help us loosen 
up and it increases oxygenation throughout our body which is another good thing for mood 
and everything else and if they've shown that exercise actually does increase serotonin levels 
so why not now exercise does not have to be going to the gym it can be playing with your dog it 
can be closing the blinds so nobody can see you and dance like nobody's looking whatever it is 
that moves your body is exercise and it doesn't have to be 30 solid minutes you know that may be 
way too much for some of our clients if they can do a commercial break they're watching TV maybe 
they can do crunches or whatever their doctor approves that is exercised anything to get their 
body moving and eventually we'd like to see them get to the point of getting at least 200 minutes 
of moderate exercise per week not per day per week we want to help them eliminate unnecessary 
stressors and that's a behavioral thing if you don't like driving in traffic if it stresses 
you out well then how can you get around that can   you take the train into work can you carpool into 
work can you leave earlier so you're not driving through traffic can you work from home think 
about different ways and you know have clients list all of their stressors nunno stressors too 
small let's just get them all out here and and lay them all out you can do it on index cards you 
can do it on a whiteboard I prefer the whiteboard   so we don't kill trees but whatever and let's 
figure out everything that stress is you have and then let's start marking off the ones that 
you can just work around or get rid of and then what's left let's figure out how to mitigate 
those encourage things to encourage people to do things they enjoy to relax life is not just 
about work and sleep now sleep is important and and so is work but we also need to have time to 
relax one of the activities I do with my group sometimes is I'll bring in a box and I'll have 
representations of different stressors I'll have bills in there and a little toy car that's been 
banged up and various other stressors and I'll have all this in the box and on and we talk about 
reducing stress and eliminating stressors and so we talked about how to eliminate each one I pulled 
them out of the box and then when we're finished I show them the box and I'm like well what else 
is in here there's nothing you have to add in the positive because you want to fill yourself up 
with positive if you just eliminate the negative   the positive generally doesn't magically spring 
up we want to help them figure out what makes them happy and encourage them to do something for 
30 minutes a day I know that's a big big jump for a lot of people 30 minutes a day that they enjoy 
and it helps them relax and they should laugh often one of the quote prescriptions I give to 
a lot of my clients is I want you to listen to some sort of comedian or some do something that 
makes you laugh for ten minutes a day laughing for ten minutes is a lot but you know you can find 
10 minute videos or whatever on TV that are on YouTube that are really humorous and a good laugh 
can increase your immune system as well as reduce cortisol levels that's you know better than any 
drug can do in in many ways another behavioral technique is environmental grounding encourage 
them to look into Fung Shui or just look around their room their office their car their home 
and eliminate unnecessary stress when they're sleeping you know they don't want to have a window 
behind their head if possible they want to be able to see all entrances and exits to the room that's 
just a function cippolini cup on you because when there's a possibility of that then we tend to have 
this low level of anticipation encourage people to look around so they have an environment where they 
feel like they're not gonna be trapped they feel like they're free they're safe and they feel like 
they're free from getting startled and that can   be by somebody walking up on them or even by loud 
noises we have dogs and when the when the UPS man comes it gets really really loud if somebody has 
aversion to loud noises like banging cabinets or barking dogs whatever they may consider at certain 
times a day when they're trying to relax having noise cancelling headphones on and that can help 
blunt that startle response so they're not jumping out of their skin keep a light with a red bulb 
or yellow if red is a trigger some people were when they experienced their trauma there was sort 
of a red light so if red is a trigger then don't go there but yellow just not blue because blue 
messes up your circadian rhythms keep a light with a red light bulb by the bed so when you wake 
up you can turn that on and get reground ‘add the unit that I ran for veterans we used to have a 
lot of veterans that had night terrors and that was one of the things that we did so when they 
woke up they could get reoriented really quickly but they wouldn't completely destroy their 
sleep cycle and they wouldn't wake up their entire entire unit if a nightlight is needed 
some people do need night lights and this can be for older people or people with you know 
really bad night terrors whatever ensure that it's no more than 5 watts and is yellow or red 
to minimize disruption to circadian rhythms so if you have to have a nightlight on consistently 
don't use a blue light or a white light because the brain registers that as time to wake up for 
some people it's hopeful depending on what the trauma was for some people is helpful to get a 
dog if they were victimized by another person or you know after if they were in combat and they 
were always on alert for other people that might want to hurt them sometimes a dog can be a good 
tool because people can go to sleep and they know that the dog is going to wake up and bark if it 
senses anything is a little bit amiss and people tend to be much calmer when they have that you 
know living breathing burglar alarm so to speak now on to the cognitive stuff understanding is 
the place where I start with a lot of my clients when people see how their symptoms make sense it's 
easier to deal with them avoidant symptoms after a trauma you don't want to go back to that again if 
you were in a house fire you certainly don't want to think about something that is going to set your 
house on fire again that's going to trigger those memories your brain doesn't want to remember that 
and your body and your brain doesn't ever want to be in that situation again where it might be 
exposed to a house fire so avoidance makes sense that's dangerous don't go there hyper vigilance 
makes sense it's your body going okay you were resting on your laurels the last time and it kind 
of [ __ ] in the butt and look what happened you were exposed to this trauma whatever it was and 
now you need to be more alert in the combat trauma is a little bit more different or a little bit 
different because you know they are constantly hyper vigilant waiting for somebody to come 
attack them but hyper vigilance makes sense it's your brains way of going hey I want to live so 
I need to stay extra alert so I don't get caught unawares intrusion flashbacks make sense when 
trauma happens you know when things happen let's start that when things happen you know you drive 
across town and you know get to your house and you parked your car and you see a package that's 
sitting there whatever all of those things make sense you owe the postman brought a package let 
me get it let me open it you integrated it's like what happened was supposed to happen and you file 
it away in your memories things make sense trauma does not make sense trauma does not make sense so 
a lot of times people have difficulty integrating that it's like what do I do with this I thought 
the world was safe but not now or it seems like everything's dangerous then you're telling me I'm 
safe I don't know how to integrate my experiences with current and past reality so they're stuck 
with this thing in their amygdala going okay there's this traumatic reaction and we really 
don't want to go back there again but I don't   know what file to put it in what memory file so 
it's hanging out there kind of like a loose end and negativity well you know think about it after 
something bad happens and you don't know exactly how to deal with it so you want to protect 
yourself instead of saying okay that was a bad situation you know everything else is fine 
we tend to over generalize to a certain extent and we may become more suspicious of other people 
we may become more negative in our interpretations looking for ulterior motives it makes sense 
we want to survive once people realize that and they start saying okay you know I thought I 
was just you know weird or something no that is your body now what we can do is figure out what's 
making these things happen and figure out ways to deal with it many people who get who experienced 
trauma have difficulty integrating that trauma into their schema so they get stuck in that fear 
or the amygdala in the back of their mind going I told you so it was dangerous you know gotta pay 
attention to me next time loop so we really want to quiet that amygdala down he's he's a nervous 
Nellie or she uh huh one of the first steps a lot of clients feel like they need to go through 
and you know when I work with clients with PTSD I don't necessarily start with telling your story I 
like to make sure that they have a safety plan and that they are as energized and recharged as they 
can be they've prevented as many vulnerabilities they've got as much cortisol as possible before 
they start telling their story so it doesn't you know trigger a crisis not everybody's willing 
to wait so however you end up doing it with your clients is how you end up doing it but when they 
tell their story it's very difficult for a lot of clients to relive that experience while sitting 
there looking someone else in the eye and sitting   still you know think about how uncomfortable 
it is to tell somebody about the worst or and sometimes the most humility a humiliating moment 
of your life while sitting there looking them in   there in their face and they're just nodding and 
you're like I really don't want to be telling you this so there are ways to make it a little 
bit more comfortable one thing can be to ensure the client has something to focus on sometimes 
bouncing a ball against tennis ball against the wall can be something they're focused on that 
tennis ball and they're grabbing it and they're talking to you that's fine you know if you've 
got a racquetball court outside or you can go   outside and there's a brick wall they can throw 
a tennis ball against that can be a good place to be so they are focusing on something outside 
of themselves you don't have that you can pass a ball back and forth you can bounce a basketball 
if you've got a place to do that something where they have to be using their body some people 
prefer to swing and look at an object like a wind chime I know a couple of therapists who have 
swings in their office they're those kind of like egg-shaped chairs that you can sit on and they're 
suspended from the ceiling and people can swing sort of rhythmically which is comforting for some 
people and they can watch a wind chime they're not having to look at the therapist and some 
prefer doing something they enjoy like cooking or exercising now obviously confidentiality is 
huge here so you've got to figure out where you can go whether you're doing an in-home session or 
if you have a place that you can go where people can talk freely and no one's going to overhear 
them but those are all techniques that you can use while the client is telling their story 
to help keep them moving forward make sure the client feels safe and reassure them regularly 
that they're safe when you're talking to them continually use past tense words and reaffirm for 
the client that they are safe in the present such as if they're telling you about something that 
happened when they were a child you can talk about   how wow that was really overwhelming for you at 
that age or if you're working with a veteran you can talk about when you were deployed you were 
constantly on edge and talking about things in the past making sure that they recognized and can 
start differentiating the past is back there that traumatic event that awful thing that's on right 
here on the timeline and we're here now it doesn't mean you're not upset now however you don't 
have to bring all of that with you EMDR does a lot more with that it's a lot more in-depth 
but if you're not AMV are trained and your work struggling to help clients tell their story those 
are some techniques you can use to help them start articulating cognitive behavioral therapy for 
trauma is another technique that is used mainly with children to help them deal with traumatic 
experiences and you can find trainings on that I've got a couple of videos on that on the YouTube 
channel as well as podcast episodes but there are techniques that can be used and that involve 
helping people tell their story then and now help clients identify how they were different or less 
vulnerable now than they were then if you were abused when you were a child that was horrible 
and you were stuck and you were helpless because you couldn't fend for yourself now what strengths 
do you have what safety do you have help clients identify the ways the trauma changed how they feel 
about others including strangers you know people they've never seen before does it make them more 
suspicious or wary of strangers people in their own family and even their kids some people who are 
victimized as children may when their children get to be about that same age may have a resurgence 
of their PTSD symptoms because they start seeing the trauma happening to their children help them 
identify have the trauma affects how they feel about themselves does it make them feel broken 
worthless powerless or not and how did it change their outlook on life once they articulate these 
things then you can start addressing them one at a time help them address address any cognitive 
distortions by finding the exception and getting the facts for just about any cognitive distortion 
one or the other of these techniques usually works evaluate people's thinking for mind-reading for 
example in trauma somebody might say I can tell that person is dangerous or wants to hurt me 
so you know I'm reading their mind I'm knowing that they are thinking about hurting me well no 
you're not you may have your spidey senses may be going off but you don't know that that person 
wants to hurt you so look for the facts in that situation what are the facts that are telling you 
that you're in danger all or nothing thinking or polarized thinking somebody who's been traumatized 
may say I will never feel safe again well it's gonna be hard to feel safe in all situations but 
let's think about the exceptions when in the past 24 hours or you can even start with do you feel 
safe now and if they say yes you could say all right when else in the past 24 hours have you felt 
safe so they can start identifying situations in which they do feel safe and hopefully we can 
expand those situations we can't promise them that bad things won't ever happen again because 
bad things happen but we can help them recognize that the majority of the time they are safe 
those are the facts and then they can start addressing factual versus emotional reasoning 
in emotional reasoning we think that something is what it is because we feel a certain way so 
if we feel scared then we figure out a way to convince ourselves why this is scary you know 
if I'm getting ready to go do a presentation   to 200 people and I feel anxious then I might 
start trying to think about all the reasons why this is terrifying and that's emotional reasoning 
factual reasoning would be you know I'm getting ready to go talk to 200 people let's think about 
in the in facts how many times have I done this   before have I ever you know passed out on stage 
or whatever I'm worried about no so helping them differentiate fact from feeling catastrophizing 
my life is over I'm ruined there's a lot of that for shorten future sort of thinking that happens 
after trauma again half people look at the facts of the situation is your life over you know 
is there nothing meaningful left in your life and you have to be careful how you phrase these 
questions because that's kind of rude to say so you're saying there's nothing meaningful left but 
you want to get to that generally by helping them see that you know there are still some things in 
their life that are meaningful overgeneralization again have them look for exceptions if they see 
that you know maybe they were attacked by a person that looked a certain way now every person that 
is of that same gender ethnicity whatever they see they think is dangerous we want to help 
them start looking for exceptions to that rule should a lot of times people blame themselves 
I should have known better or I should have turned off the oven or I should have done this 
that or the other we can't change what happened in the past so we want to help people look for 
the facts a lot of times people did the best that they could with the tools that they had at 
that time some people when they are exposed to trauma freeze they don't fight they don't flee so 
they start blaming themselves for what happened I should have run I should have screamed but you 
couldn't you know it's just one of those things that you did what you could do at the time 
now what do we do to move forward and then the recency our availability heuristic is when the 
person judges life forever and ever based on what recently happened so if they were attacked in a 
parking garage or they were in a high-rise when it caught fire whatever the trauma was they may start 
thinking parking garages are not safe never ever well that's just because that recent experience 
they had is so prominent in their mind they've walked through parking garages 500 times before 
in their life and nothing bad has happened so we want to help them look at the facts and really 
separate high probability from low probability Nancy points out that there is another technique 
where you can ask people if their I feel a hundred percent safe at this moment and if they don't 
then you can talk about what would help you feel a hundred percent safe and encourage them to 
start working towards that in developing areas and times where they feel a hundred percent safe 
and then expanding that it's you know like Nancy says it's hard for them to do a lot of times but 
it is possible and once they start finding these places where they feel a hundred percent safe 
they can breathe constructive self-talk help clients develop survivor scripts use button pins 
those little pins that you put on backpacks I love using those in group activities and have people 
write constructive self-talk on those pins so if they frequently say things like I should have run 
or I should have fill in the blank whatever it is have them find a constructive response I did the 
best that I could or what whatever works for them and create a button pin out of that and then they 
can have a whole sash or wall or bulletin board of button pins they can also do a collage or we've 
done before in in my trauma groups a ribbon tree and it looks a lot like a Christmas tree but they 
create ribbons you know like the little ribbons we wear around for breast cancer awareness or any of 
those other things and they write the constructive self-talk on those ribbons and we hang them from 
the tree so the tree is filled with constructive self statements speaking of trees you can use 
the tree metaphor I like the tree metaphor but I'm kind of one of those tree hugger people have 
clients start out by describing the tree what do   you see describe this tree to me then have them 
describe how the tree might represent their life and you know you can spend quite a bit of time 
on this in group ultimately what we want to get to is trees or beautiful vibrant and full of life 
there sturdiness provides shelter for vulnerable creatures so because they are strong because of 
everything they've gone through they're able to protect others all trees are impacted by their 
environment you know if it's too salty it may make the leaves wither a little bit if it's you 
know they're not getting enough water so it's   important for them to be in a healthy environment 
so they can grow all trees have unique shapes based on what happened to them and what was pruned 
or not as things happen you know this tree has a split down the middle and it could be that there 
was a stone that was there that kept it so it had to grow up and around or I don't know it could 
have just grown that way but every tree has its unique shape based on its own experiences if it 
was droughty if it was raining if it you know our donkeys will regularly eat the bark off part 
of our trees so then you know part of it will   die off and that shapes that tree that happens to 
all of us we are shaped by all of our experiences trees are rooted in the dirt which is made up of 
remnants of the past so every year the tree sheds its leaves or the pine needles fall down as they 
die and they decay and they make the soil that eventually feeds the tree so what we create what 
we're exposed to we also use to feed ourselves so we want to expose ourselves to positive 
things and feed ourselves with positive things another activity you can do is logging I'm a 
behaviorist heart keep a log of flashbacks or startle responses or both when they occurred 
what triggered them if known their intensity on a scale from one to five how well the person 
had slept the prior night the amount of caffeine alcohol or nicotine in the preceding hours 
because stimulants tend to trigger the startle response and keep the HPA axis revved up and prior 
stressors that day again if they were already if their HPA axis was already revved up if they were 
already worn down from being under chronic stress then they may be more vulnerable to flash backs or 
startled responses use these logs to help people chart the reduction in frequency or intensity of 
the intrusive or hyper-vigilant symptoms if they feel like they're not getting any better you know 
let's look let's see if maybe you're still having flashbacks twice a day but the intensity has 
gone from a five down to a two okay you know you're still having them and we'll work on that 
but the intensity is decreased we want to help them see those small steps in the right direction 
and the logs can also help them identify triggers or vulnerabilities such as too many stimulants or 
not enough sleep and it starts helping them see how their body and taking care of their body is 
so important in helping address the PTSD symptoms ABCDEF is one of your basic cognitive behavioral 
strategies is effective for anxiety and negative I don't ever use this for intrusion because 
intrusion is not something people I don't want them to think that they bring it on themselves I 
want them to use this in order to address things that they do have cognitive control over and 
they can choose not to think that so activating event what happened you know somebody you saw 
you saw a fire truck drive by and it reminded you of when your house caught on fire okay 
so you start having anxiety going oh I hope that's not going to my house now and getting 
all worked up about it so you get upset those are the consequences encouraging people to look 
at the beliefs about this activating event the beliefs about that fire truck that went by that 
triggered their anxiety and dispute them for their rationality how rational is it to assume that 
it is going to your house or for people whose houses got struck by lightning you know when a 
thunderstorm comes along and they start to get panicky you know encouraging them to identify 
that the thunderstorm is the activating event the consequences they're getting upset what are 
their beliefs well one of them is probably we're going to get hit by lightning again so then 
addressing whether that is probable or not and figuring out how to address it and then 
E is evaluating the most productive outcome so let's stick with the the lightning for right 
now is worrying about it worth my energy no you can't control whether lightning is going to 
strike you or not you know you can be inside   and you can be in a safe place but after that you 
can't control whether it's going to hit your roof unfortunately so how can I best use my energy 
to deal with or let go of the situation what can I do to help myself get through and improve 
the next few moments while we're in the storm systematic desensitization on the other hand 
is helpful for intrusion have them identify a feared situation such as being at home alone maybe 
they were home alone when they were attacked so being at home alone is terrifying have them 
identified think about it you know being at home alone during the day first imagine it have 
them rate their anxiety on a scale from one to five and then use deep breathing and grounding 
and mindfulness skills until they can imagine it and not feel bothered so the deep breathing 
in for four out for four triggers the rest and relax response grounding skills are can include 
telling themselves you know where they're at and that they're safe and even looking around in 
identifying five things that they see four things that they hear three things that they smell two 
things that they can touch and one thing they can taste that helps them stay grounded in the present 
moment instead of going back where ever there was but encourage them to practice this and it's not 
going to happen the first time encourage them to practice this until they can imagine being at home 
alone during the day and it doesn't really bother them they're like you know what I think I can do 
that once they can then you ramp it up a notch so the next step maybe being at home alone for ten 
minutes after everyone leaves in the morning so people just left so you know that you know there's 
lots of activity going on you know you were safe ten minutes ago can you feel safe for ten minutes 
once they get to the point where they can imagine it and not feel anxious take it up another step 
so just stay home alone during the day for thirty minutes when you know a neighbor or that your that 
is your friend is home so you know you could call that person and they would come right over get 
to the point where the person can do that without getting anxious then staying home alone during 
the day for an hour and then staying home alone till it gets good and dark you know it gets dusky 
and then it starts to get dark I remember when I   was a little kid as soon as it started to get 
dusky I was like okay once mom getting home um and then staying home alone after dark and 
then the biggie for a lot of people is going to sleep when they're home alone and there may 
be other steps in between for different people but basically it's like a ladder and you want to 
help them gradually get to the point where they can approach their feared situation and not feel 
anxious they start out by being able to imagine it and then they work up to being able to do 
it without experiencing high levels of anxiety dialectical behavior therapy is awesome for 
anxiety negativity withdrawal and avoidance and even to a certain extent intrusion you 
want to prevent vulnerabilities which means help the person figure out what they need to do 
so they're on their a-game so there is rested and there cortisol's all in balance and everything 
as best as they can good sleep good nutrition good social support all that stuff encourage them to 
practice mindfulness to prevent vulnerabilities so they're aware of how they feel in the moment 
and they notice when they're starting to get   tired or they notice when they're starting to 
get stressed so they can address it early and use mindfulness to prevent or mitigate triggers 
when they notice something's going on then they can address it earlier or if they're at a 
friend's house or even at home watching TV   and a commercial comes on commercials are big 
triggers for me and a commercial comes on or a television show has a scene in it that's 
triggering they can ground themselves and they remember those triggers they remember those 
techniques such as 5 4 3 2 1 help them understand that distress is inevitable because if people are 
trying to recover from trauma and they think well I need to make it all go away they're going to be 
sorely disappointed but they can develop distress tolerance skills including urge surfing and the 
acronyms accept and improve and those are things that you can look up online or on the dot in the 
dialectical behavior therapy episode but except stands for activities comparisons contributing 
emotions pushing away and sensations in order to help people get through that place where 
they're feeling the adrenaline rush until   they can get into their wise mind and decide 
what is the best next step improve stands for imagery meaning prayer relaxation one thing at 
a time take a mental vacation and encouragement self encouragement or encouragement from others 
it doesn't matter let's get some encouragement   and DBT also encourages people to embrace the 
dialectics recognizing that every situation has good and bad aspects so if they can embrace the 
bad with the good then it's going to be a much easier Road than trying to find situations 
where there's only good and there's no bad it just really doesn't happen acceptance and 
commitment therapy is another great tool that can be effective for anxiety negativity withdrawal 
and intrusion and a CT people learn to accept what is in the moment it is what it is and in DBT they 
call it radical acceptance in a CT people learn how to diffuse from their thoughts so they're 
not connected to it anymore instead of saying I am terrified or I am in danger that's fusion 
with your thoughts saying I am having the thought that I'm terrified or I'm having the thought 
that I'm in danger because all of us who are getting older know that thoughts can come and go 
even before you make it into the room to remember   what you were going in there for but thoughts 
are different than who we are a CT encourages people to define their goals and values so they 
figure out what's important to them what do I   want to focus on what things do I have going for 
me and choose purposeful action choose to do the next thing that's going to help them get closer 
to their goals and finally he talks about living in the and and I love this concept living in the 
and understanding that you can have a rich and meaningful life and experience fear sometimes 
and experience distress sometimes I can stay home by myself and feel anxious you know I can do 
both of those and I can get through it cognitive processing therapy is effective for anxiety 
negativity and withdrawal you want to help people evaluate situations and their beliefs looking at 
the facts for and against their belief identifying whether their fact their belief is based in fact 
in emotions like we talked about earlier or just in habit you know they've always thought this way 
so they're continuing to think that way you know that may not be the most accurate way to go are 
they using cognitive distortions all-or-nothing thinking personalization mind-reading we talked 
about those if so address that are you focusing on only one aspect of the event or confusing high 
and low probability like the house getting struck by lightning a second time are you focusing 
on irrelevant factors you know all of those are yes or no questions is this thought getting 
you closer to what you want and if not what is a better thought that helps you get closer to what 
you want what are the advantages or disadvantages to thinking this way and what difference will this 
make in a month or a year oops trauma impacts the person biopsychosocial e behavioral interventions 
can help them prevent and address avoidance and hyper vigilance which is great you know we really 
want to help them be as physically strong and well-armed as possible and have that HPA axis 
in sync have their circadian rhythms in sync so their cortisol is in sync so their body is ready 
to deal with life as life that's the first step and then the cognitive interventions can help 
them understand the function of their symptoms   to choose effective ways of dealing with them you 
know the function is to help me survive okay well first I need to figure out in the present am 
I really in danger or am I just reacting from the past address unhelpful cognitions about the 
trauma themselves in the world reduce chronic stress to help the HPA axis rebalance and recover 
and assist the person at integrating the trauma narrative so it's not a loose end that's 
just kind of sitting there an amygdala in   the in their amygdala they've made some sort of 
sense they've closed that chapter on their life between writing notes filing insurance claims and 
scheduling with clients it can be hard to stay   organized that's why I recommend therapy notes 
they're easy to use platform lets you manage your practice securely and efficiently visit 
therapy notes com2 get two free months of therapy notes by just using the promo code CEU when you 
sign up for a free trial at therapy notes com if this podcast helps you help your clients 
or yourself please support us by purchasing your CEUs at all CEUs calm or getting your 
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