O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Post-traumatic Stress Disorder and Post-traumatic Stress Injury

 Responding to first responders and PTSD

Responding to First Responders:  PTSD and PTSI in First Responders

Psychologists sometimes treat first responders to an emergency. We may see police officers, firefighters, hospital staff, paramedics, and clergy who have suffered psychological trauma after responding to a natural disaster or critical incident. First responders may come to us to help them with post-traumatic stress disorder (PTSD), substance abuse, chronic pain, depression, and anxiety. Treatment for first responders and their families is further complicated by their access to firearms, which increases the risk of suicide.

The symptoms of PTSD, include hyper-vigilance, insomnia, flashbacks, and nightmares. Another “post-traumatic stress injury,” or PTSI. A traumatic injury implies that the reaction to a critical incident must not necessarily lead to a psychiatric disorder or become a chronic condition. Diagnosing a “disorder” may lead first responders to believe that their reactions are wrong and that they won’t get better. By using the word “injury,” we empower people to feel they have some control over how they recover from the event. In the words of Matthew J. Friedman, executive director of the Department of Veterans Affairs National Center for PTSD: “The concept of injury usually implies a discrete time period. At some point, the bleeding will stop. Sometimes the wound heals quickly, sometimes not. A disorder can stretch on for decades.”

An emergency can present first responders with a critical incident—that is, a sudden, unexpected, unusual event that includes the loss or threat of loss of life. First responders who perceive a threat or trauma can react in significant psychological and physiological ways. It’s important for the treating therapist to understand the meaning clients attribute to a critical incident, which affects how it is processed. Police officers at a violent scene might be excited, afraid, or just wonder about what’s for dinner that night.

Stress, left alone, is neither harmful nor toxic. Whether the stress becomes damaging is the result of a complex interaction between the outside world and our physiological capacity to manage it. – John J. Medina, Ph.D.

Our body’s reaction to stress is partly a matter of what stress we encounter, partly its duration, and partly what the responder brings to the event. Other life events can also play a role in reactions to critical incidents. At least 60% of adults in the United States have experienced at least one traumatic event in their life, such as child maltreatment, interpersonal violence, natural disaster or serious accident. Exposure to traumatic events is a risk factor for depression, substance abuse, and PTSD. When a parent or other significant adult has traumatized a child, scars are left that can re-emerge in adulthood. Depression is the most common effect of trauma. However, most who have experienced a critical incident don’t experience long-term consequences; in fact, only about 7% develop PTSD/PTSI, although the percentage is much higher in the military, at 20-30%.

Trauma response doesn’t come out of nowhere. Most people diagnosed with PTSD have had at least two traumatic events in their life. In a study by John Briere (2012) that attempts to predict PTSD, he found that psychological neglect in childhood accounts for the largest percentage of variance, rather than the threat of physical injury. In treating clients with PTSI, it is important to explore the particular incident to which your client’s reaction is tied.

Betrayal for first responders takes four forms: administrative, organizational, personal, and community. An example of betrayal is keeping the first responders locked in a debriefing room, away from press and victims while investigations proceeded—with no provisions made for food or water. This constitutes an institutional failure, or as psychologists would say an empathic failure, and compounds the trauma. In the aftermath of catastrophic events, sometimes the most obvious way to support a traumatized worker is to take care of their physical needs.

Another kind of institutional betrayal was failing to protect a first responder from the press—for example, allowing private observations to be publically recorded. Such inattentiveness and lapse of judgment serve to make the primary trauma much more complex by re-opening wounds from childhood that, when coupled with intense life-threatening trauma, can lead to PTSD or PTSI.

In treating trauma, it is important to:

1. Acknowledge it and move toward forgiveness
2. See the connection between the current critical incident and personal history
3. Help the responder understand why it is so powerful
4. Get peer validation for the first responder’s experience

“What separates people who develop PTSD from people who are merely temporarily distressed is that the people with PTSD start organizing their lives around the trauma.” Bessel A. Van Der Kolk

Treatment elements include cognitive restructuring, development of cohesive narrative, affect regulation and relapse prevention. The real work is ongoing support, through individual and group meetings. Couples and family therapy is also a major component of treatment. Peer support and 12-step programs designed to help first responders are important adjuncts to therapy.

Kamena, M., Kirshman, E., and Fay, Joel(2013). Counseling cops: What clinicians need to know. New York: Guilford Press.

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Seeing How Childhood Patterns Affect Marriage

 

Couples Therapy and Family of Origin
Learning about Relationships by Watching Parents

When Mark and Judy came to see me for couples therapy, Judy felt frustrated by her husband’s constant angry mood. They rarely talked anymore, and she felt that any time she brought up a stress, the conversation quickly became a quid pro quo—who had the hardest day? Mark felt low-level irritability and frustration about his life as a parent, provider, and worker. He didn’t feel in control over his life, but rather, at its mercy. ”When do you relax? What do you do?” I asked. He answered, “I veg.”

“How do you veg?” I asked.

“I turn my back on my wife and small kids and look at my laptop, surfing the web, reading this or that,” he replied. Turning his back was Mark’s signal to his family not to bother him, his way of carving some space for himself in his small house. But did it work?

“It works for moments, maybe; they leave me alone, at least.”

But in turning away, Mark was missing the opportunity to turn toward anything enriching. The web gives ample opportunity to veg, plenty of material to inspire reverie, but the end result is not Whitman’s loafing that invites the soul. It is diffuse and at the end of the evening, empty. A one-click purchase was often the only way my client felt like he actually got something for himself.

 Spillover Stress: How it Damages a Relationship

And the next day would be just like the one before, full of stress and angry feelings. The psychological term “spillover” describes how stress can bleed into other aspects of life, especially in relationships. When someone is stressed because of the demands of daily life, they will carry that stress home, like a heavy briefcase they can’t put down. If someone is disconnected from himself or herself because the demands of life feel so heavy, they lose connection to their inner self, the soul.

Using Reverie and Daydreams as an Alternative to Surfing the Web

Returning to my client, I invited him to consider the benefits of reverie. To daydream, to muse with no clear focus, to allow the mind to wander with its spirals and twists—that can be a wonderful thing. “Loaf and invite the soul,” wrote Walt Whitman in Leaves of Grass. We need moments in the day with no one—not even ourselves—looking over our shoulders and monitoring our productivity. We need time where we can let ourselves slip into that pleasant, non-productive time with nothing to do but allowing thoughts, feelings, and images to freely enter and leave our minds.

So why not put the briefcase down, take the weight and the ache away? In Mark’s case, as we explored his feelings more deeply, he revealed guilt: Guilt about taking time for himself. Guilt about not being 100 percent there for his wife and kids. In therapy, we explored some reasons for this.

 Going Deeper Within the Context of Couples Therapy

Through his boyhood and teenage years, Mark was what therapists call a “parentified child.” His mother suffered from a degenerative disease. His father worked to support the family on a meager budget, despite working two jobs. Mark had to care for his mother, feed her, and stay home while the other kids were out playing.

He got the message that taking anything for himself when his poor mother had nothing—no mobility, no joy, and no friends—was selfish. He carried this guilt into adulthood without realizing that now, as a parent himself, he was recreating his childhood pattern and taking care of everyone but himself.

While at first glance Mark and his wife Judy’s marriage looked like that of a typically bickering couple, it wasn’t that simple. Just teach them some communication skills, give some homework, and let them go on their merry way? NO. Unless the two understood Mark’s guilt and the reasons behind it, no real, lasting change could be made in their marriage. They would fall back into old patterns six months or less after completing couples therapy.

In Mark’s case, Judy listened quietly at first then interjected, “But I do give you space—I tell you go see your friends one evening after work, go the gym…” Mark had heard her say this countless times since their daughters were born. The conversation was an old one and never changed. When people have the same fight over and over, they become bitter and hopeless. Thoughts of divorce enter along with feelings of self-pity. “Another partner would not treat me this way,” each might think.

 Stepping Out of Gridlock Takes Patience and Time

To step out of a gridlocked conflict such as this one takes patience and time. Couples counseling creates a space for partners to explore some of the not-so-obvious dynamics of their relationship with empathy, putting grudges aside long enough to really see your spouse in a different light. It provides an opportunity to see patterns on many levels: communication with your partner, your relationship to your parents, and how those layers interact with each other to create difficulties in loving.

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Finding Tranquility in Meditation Despite the Inevitable Storms

Buddha Muchalinda
Buddha Muchalinda

One of the stories from the life of Buddha that is depicted in numerous sculptures from many cultures is that of Muchalinda, the serpent. The story goes that during the sixth week after Buddha attained full enlightenment, a weeklong torrential rainstorm threatened his meditation. Muchalinda, king of the serpents, emerged and protected Buddha with his body. Because the serpent king felt compassion for the monk, he spread out his many multiple hoods to protect him.

The commonality between these images across cultures is the hands placed in meditation mudra (dhyana) gesture with the palms facing upward and the right hand over the left.

Learning to Trust the Safety of Your Meditation

The calm tranquility that is conveyed in these sculptures belies the raging storm outside the snake’s shelter. During meditation, the mind’s turbulence, the fuming of emotion, and the body’s discomfort frequently threatens to disrupt the practice.

In the discourse of the Eightfold Path, Buddha describes right mindfulness to his monks:

“Here, monks, a monk dwells contemplating the body in the body, ardent, clearly comprehending, mindful, having removed longing and dejection in regard to the world. He dwells contemplating feelings in feelings, ardent, clearly comprehending, mindful, having removed longing and dejection in regard to the world. He dwells contemplating mind in mind, ardent, clearly comprehending, mindful, having removed longing and dejection in regard to the world. He dwells contemplating phenomena in phenomena, ardent, clearly comprehending, mindful, having removed longing and dejection in regard to the world. This is called right mindfulness.” (In the Buddha’s Words: An Anthology of Discourses from the Pali Canon. Edited by Bhikkhu Bodhi, 2005, pp. 239-240)

Finding Shelter Within

It is by noticing our emotions (such as longing or dejection) as they arise in our physical sensations, thoughts, and feelings that we bring insightful awareness to our meditation practice. Even the most practiced meditators get pulled away from their focus sometimes. There will always be storms. Finding a shelter within yourself, where you can rest while you continue your meditation, will help you to stay steady during a storm.

Stories and myth help us by giving symbolism and metaphor to common experiences. Just as Muchalinda sheltered Buddha, sense your own shelter coming from within. By thinking of the snake as a compassionate protector, you can bring kindness and strength to yourself as you sit, despite the inevitable disturbances in your emotional environment.

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Six Ground Rules for Introducing a New Girlfriend or Boyfriend to Your Kids

hiding from emotions is never a good strategy

When is it okay to introduce your kids to a date after divorce or separation?

This is a common question for newly separated or divorced parents. Like so many things involving children after divorce, the answer is “it all depends.” But there are a few ground rules that can help in the transition to dating.

In evaluating when to let children know about a new romantic partner, the goal is always to protect the child’s psychological best interests. Much depends on the child’s age and the quality of your relationship before and after your separation. As noted in a previous post, watching parents treat each other with disrespect and lack of affection harms kids even more than having to shuffle between two homes.

Everyone is different with regard to dating readiness. Some people will wait for months, some for years. Consider, though, that when a relationship has been unhappy, it’s important to give yourself time before jumping right into Match.com or eHarmony. Make use of this found time alone when you do not have the kids. Get to know yourself again. People are often surprised to discover that they can enjoy a kid-free weekend or weeknight without feeling guilty. Many have said it is an unsuspected silver lining in divorce. Time alone without kids is often a rarity in marriages where fathers and mothers both devote themselves to family life and the nurture and growth of their children.

Individual psychotherapy during this period can help you to reclaim the parts of yourself that have been lost or damaged. Taking this opportunity before dating again will help you, your kids, and your eventual romantic partner. No one wants to date someone on the rebound from a marriage. Dating to fill the void or to build your self-esteem will not work in the long term, bringing more harm than comfort.

Eventually, the time will come when you feel ready to explore relationships again. When the transition to living separately is established and custody has been worked out, agreed upon, and is going smoothly, parents will begin to think about dating.

Keep in mind the following suggestions to help you, your kids, and your ex ease into this new and often threatening territory.

Some Guidelines for Dating Post-Divorce

1. Children need to establish a routine with each parent. This is best done when the custodial parent is fully present, undistracted by a romantic interest.

2. Dating should be done during non-custodial times. The introduction of a new partner is often confusing to young children, especially during the first year after a divorce. In older kids, who may be exploring their own sexuality, seeing their parent with another partner can make them feel self-conscious and embarrassed.

3. It is important to not create a climate of anxiousness about where they belong in each parent’s lives. Children need to feel like they come first. If a romantic partner is introduced too soon, this sense of secure attachment will be compromised and can create anxiety.

4. Do not bring a partner home for the night on your evening with your child. Waking up in the morning and seeing that a parent’s boyfriend or girlfriend has slept over can be confusing and hurtful. Kids will feel an allegiance to their other parent and will feel protective of them, fearing they’d be hurt by knowing that there is someone else in the house.

5. When the time comes to date openly, it is a courtesy to inform the other parent. Letting your ex-partner know that you are dating and want to introduce a serious relationship to your children allows the non-dating partner to process this news without being blind-sided, for example by seeing you with another person at children’s events. Do not let your children be the ones to tell the other parent that mommy or daddy has a new love, and certainly don’t ask them to keep secrets from their other parent. They should not be put in this position. When children innocently expose this information, it can engender angry and painful reactions that can cause the children to feel guilty, sad, and embarrassed.

6. Always treat your ex-partner with respect whether their non-custodial parent is present or not. Kids learn from watching. When you begin to date, show respect to your ex-partner and to your children by not flaunting your new partner. Respect boundaries with regard to public displays of affection. For an ex-spouse to see their former partner kissing during a recreational event will most likely cause anger or hurt. It is common for one party to feel jealous or possessive when they realize that their former spouse is dating. This is a tender time for everyone. Remember to be kind and respectful to each other. This role-modeling will help your children to assimilate a new person into their lives in a healthy way.

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How Couples Counseling Can Guide a Divorce That’s Better for the Kids

Staying Together for the Kids: Why This Isn’t a Good Idea

In my work as a counselor, I approach every couple with the intention of helping them heal what isn’t working in their marriages. I know that even the most challenging issues are often repairable. But occasionally, it is in everyone’s best interest to separate.

Parents considering divorce often find the very idea of being without their kids part of each week is unthinkable. The reason so many people stay in unhappy marriages is to avoid losing their children and to spare the kids the pain of not having both parents always present.

Research by Dr. John Gottman has shown that couples wait an average of seven years after becoming aware of problems in their marriage to seek counseling. This period of time can be subtly or obviously harmful to your child’s mental health. During those years when your relationship is not working, your kids are being affected—despite your best intentions to protect them.

While statistics often cite the harm divorce causes children, many studies fail to factor in the harm caused by a bad relationship. When your marriage has deteriorated into loss of intimacy (loving gestures, emotional closeness) this may be internalized by children and can affect their ability to love and be loved in their adult relationships. Likewise, when parents are obviously hostile and negative toward each other, kids may show signs of distress such as anxiety or depression with symptoms of guilt, worry, and low self-esteem.

When is it time to leave an unhappy marriage? Some reasons to leave an unhappy relationship are obvious: verbal, physical, or sexual abuse; ongoing substance abuse; broken trust through unaddressed lying and cheating; and a myriad of other extreme reasons. But sometimes the reasons are less obvious: sexual desire discrepancy, loss of respect and love, and unresolvable communication problems.

Divorce and Good Communication

Children are harmed when they are used as pawns by hostile parents: for revenge, for example, or to increase support payments. If the primary wage-earner in the family is resentful of having to pay spousal support, and seeks to reduce payments by asking for more physical custody of the children, when it is not in their best interests –this battle once activated drains emotional and financial resources—creating tension for everyone.

Kids pick up the negativity, so how you show your respect and love for their parent is important. If you are showing verbal or non-verbal signs of irritation and disrespect when talking about or to your ex, you child will be harmed. Then there are more blatant reasons, such as use of child pornography, repeated DUIs, and other criminal behaviors.

Sure You’re Getting Divorced? Couples Counseling Can Still Help

Couples counseling can be useful in learning what went wrong, not to assign blame or fix resentments, but from a perspective of taking appropriate responsibility. Doing a post-mortem of your marriage serves several important functions.

1. It helps you help your children to cope with the changes brought about by divorce. When children of divorce see their parents bickering about money, possessions, or time with the kids, they feel bad. It’s common for kids to feel guilty or responsible for the breakup. Being able to talk with your partner, calmly and respectfully, models good communication. Children pick up behaviors from their parents. Little ones are like sponges, picking up not only the crumbs but the bacteria as well.
2. If you leave a marriage without understanding what lead to its demise, you are likely to make the same mistake in your next serious relationship. In the many years I have done couples’ therapy, I have often heard this refrain: “I married someone so much like my previous partner—why didn’t I just stay?” We can’t run away from a bad marriage and assume it will be perfect with someone else. Spending time with your spouse trying to understand the complex dynamic you wove will save you from making similar mistakes in the future. Plus, couples often will decide to stay together once they realize and repair what got them to the point of divorce in the first place.
3. And, lastly, you will be co-parenting for the rest of your life. Learning better communication will help you as you raise your children in separate households. There will be many times you will have to consult each other about issues, school, friends, and problems that come up over the years. You will both need to be present at graduations, weddings, or grandchildren’s birthdays. It is a lot better to be friends working together to provide the best post-divorce environment for your kids possible.