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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How to Survive a Rip Current of the Mind When Practicing Mindfulness Meditation

Mindfulness Meditation

Ruminations and Worry Make Meditation and CBT Difficult

Recently during a visit to Hawaii, I read a pamphlet on ocean safety that described how to survive a rip current. They can travel 1-8 feet per second, meaning that in an astonishing 8 seconds, you could be carried sixty-four feet out to sea!  The instinct is to fight the rip, which only makes it worse because fighting something that powerful is exhausting.  After exhaustion comes panic, and in gulping for air, swimmers choke on seawater.

In mindfulness training, we talk about letting thoughts pass away like waves in the ocean. But what if your mind gets caught in a rip current? When the waves are so turbulent that they produce the conditions ripe for a rip?

Surviving a rip current depends on doing something that is contrary to instinct. The key is not to fight the current but to understand it and go with the flow—while at the same time, swimming across the strong current, parallel to the shore. Find a spot where waves are breaking on the shore, and let yourself be carried back to the beach by the same ocean that took you away. If you are unable to swim diagonally to the shore until the waves carry you back, then relax and let the current carry you out: it will eventually lose strength and, if you have conserved your energy, you can swim back.

The same instructions can be applied to mindfulness-based cognitive therapy. Many people come to mindfulness meditation, or Mindfulness-based cognitive therapy (MBCT) or stress reduction (MBST) depressed, anxious, or dealing with panic disorders. Asking them to sit still and silently focus on their breathing is an enormous task.  We talk about letting thoughts pass away like waves in the ocean, but what if your mind gets caught in a rip current? Often, the thought stream is too strong for the breath to anchor them, and MBCT clients get carried out to sea by their ruminations and worries.

When the mind gets carried away in a panicky current, it feels as if there is no escape. At those moments, the urge is to give up, even to quit the practice. So, when feelings threaten to overwhelm you during meditation, turn to wisdom learned from the sea.

Remember that a rip current doesn’t pull swimmers underwater; it carries them away from shore in a narrow channel of water. When your mind begins to ruminate, think of the thoughts as a channel, not the whole ocean. That channel can be overcome by allowing yourself to relax and accept the strong pull. Fighting it will wear you out. Notice where the shore is, pay attention to the flow of the water as it moves to the shoreline, and think of your body as the shore, grounding you. You are solid and firm. Ruminative thinking, like the rip current, will lose its strength eventually, and you can return your focus to your breathing. Each time you resist your instinct to fight the overwhelming thoughts and just accept them, you will be training yourself to be a stronger and smarter swimmer.

How to Survive a Rip Current

Remain calm, do not panic. Should you find yourself caught in a current that’s taking you away from where you entered the water, remember that panicking will only tire you.

  1. Go with the flow. Do not attempt to fight the current. You will almost always lose the battle. Swim across or perpendicular to the current’s direction.
  2. Wait until the current releases you. It will.
  3. Swim parallel to shore and then make your way in.

From KORC (Kauai Ocean Rescue Council)

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Depressed, anxious, or both? Part Two

Depression is a Treatable Illness

According to the National Institute of Mental Health, an estimated 17 million adult Americans suffer from depression during any 1-year period. Depression is an illness that carries with it a high cost in terms of relationship problems, family suffering and lost work productivity. Yet, depression is treatable.

Everyone feels down from time to time, and often these feelings can be attributed to a situational or environmental cause. A rift with a friend, or the loss of a job, can cause feelings of self-doubt that will leave one feeling sad for a time. But when feelings such as helplessness, sadness, or hopelessness last longer than a month, there may be more going on.

In the case of job loss, it is normal to feel depressed and worried about the prospect of finding new work and to ponder what led to being let go, or fired. But if the thoughts turn to rumination about failure, and hopelessness about finding another job, then it may be time to seek treatment.
Depression wrecks motivation through its characteristic anhedonia—Latin for inability to feel pleasure. Often this is a gradual process, creeping up over time in such a way that even the depressed person doesn’t see it coming. One day, it is there. Unshakable, unspeakable. Shame and self-doubt take hold as feelings of worthlessness erode a once-affable person. Family and friends try to help, but often give up after their attempts are met with an attitude of hopelessness.

How Psychotherapy Can Help

In my work with clients who come in for psychotherapy because of depression or anxiety, I take a careful history to see if medical problems may be causing any or all of the symptoms. Biological factors can interact with mood, increasing the severity of depression. Medical disorders such as low thyroid can mimic depression and cause some of the same symptoms such as low energy, sleep disturbance, and difficulty with focus and concentration. Once medical causes are ruled out, we reconstruct the timeline of when they starting feeling depressed or anxious. Sometimes these feelings are rooted in childhood experiences and memories, but not always. We start where the clients are, giving them a wee bit of mastery so they can feel hopeful.
Recapturing a sense of mastery is vitally important in recovery from depression. In psychotherapy, we identify what negative or distorted thinking may be contributing to feelings of helplessness. Research has shown that when someone feels helpless and out of control, they tend to avoid those situations where they are likely to feel overwhelmed. Yet, like the phobic avoidance described in the previous post, the more you avoid life, the more depressed you will become. Psychotherapy helps people to see the choices they make and to slowly incorporate fulfilling activities back into their lives. Unlike a family member making the suggestions that can easily feel like a demand or criticism-the collaborative relationship developed in counseling, allows the depressed person to take ownership for their healing. This in itself gives back a sense of control. Gradually, people can identify options and set realistic goals that enhance their sense of well-being. Whatever triggered the depressed feelings is seen from a different vantage, and automatic negative thinking begins to diminish. Going back to bed becomes less appealing as life feels more enticing.

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Anxious, depressed, or both?

Anxious people fret. Depressed people brood.

Anxious people worry about what may happen, while depressed people ruminate about what has already happened. In each case, life becomes more and more constricted.

Sometimes the two conditions may look similar because both use avoidance as a coping strategy. Think of avoidance as going back to bed and pulling the covers over your head: back to the womb. Safe and secure. Everyone has the urge to go back to bed to avoid facing some task or situation at one time or another, but depressed or anxious people turn to avoidance habitually.

In both cases, the anxious or depressed person may even end up avoiding people, places, and things they used to love. The difference is that the anxious person is avoiding occasions that trigger overwhelming, out-of-control feelings of panic, while the depressed person has lost the ability to feel pleasure in once-loved activities.

Anxiety that Causes Phobias

For instance, Julie was missing out on occasions like social and family gatherings, going to a favorite antique store, or seeing shows she used to enjoy—all because she was afraid to drive on freeways. She would go far out of her way to avoid them. Google Maps allowed her to program her navigation system to skip all freeways and bridges. But just getting from point A to point B on surface streets was too time consuming and life restricting. She didn’t apply for jobs that required driving across a bridge. She stayed home more and more. Eventually, even driving across town was daunting. She was miserable.

When a phobia such as Julie’s is pervasive, it prevents experiencing the fullness of life. Because her anxiety was interfering with her happiness, Julie was motivated to tackle her fear of driving. She came to therapy with a willingness to stick with it, even though she knew her anxiety would increase (at least temporarily). We outlined a plan that would allow her to gradually try driving on the freeway—getting on an easy entrance close to her home, and then taking the very next exit. We worked on relaxation and self-soothing so that she would be able to calm herself when she noticed the beginnings of panic. We discussed ways she could cope when she felt anxious.

Exposure Therapy Helps Master Fears

We also explored how she was holding herself back from pleasurable activities. She listed the things she would like to do if able to drive further from home, such as visiting a certain antique shop and crossing the Bay Bridge to see a show in San Francisco. Making this list helped her stay motivated when she wanted to give up.

Psychologists call what we did exposure therapy. We slowly introduce the feared situation in a way that is tolerable. This allows for mastery and gradually increases confidence. Avoidance is the opposite of mastery. It is not easy to face fears. It takes persistence and sustained motivation.

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How Lifestyle Changes Can Be Therapeutic—And What To Do When They’re Just Too Hard

The October 2011 issue of American Psychologist featured an article on how mental health professionals significantly underestimate how unhealthy or missing lifestyle factors—for instance, nutrition and diet, or service to others— contribute to many emotional health problems. It also discussed how immensely helpful improving these factors was in treating many mental and physical health problems. Researchers have termed these improvements TLCs, or therapeutic lifestyle changes.

The eight lifestyle factors include exercise, nutrition and diet, time in nature, relationships, recreation, relaxation and stress management, religious or spiritual involvement, and service to others. Plentiful research supports the importance of these eight TLCs—as does plain common sense. And each lifestyle factor contributes to the others. Exercise and diet affect mood, and recreation (inscribed in the word itself: re-creation) will help instill a sense of well-being. In a virtuous cycle, when people feel physically comfortable with their bodies, when they feel vital and energetic, they will have the energy to engage in activities such as service to others and feel inspired to spend time in nature and contribute by giving to others.

Many folks today are facing challenges in obtaining the most basic and fundamental needs, such as food and shelter and financial and physical safety. These must be met before additional needs can be addressed. Yet by addressing lifestyle factors with the means at your disposal, it may be possible to shore up your resilience, your ability to withstand hard times. Certainly, it is difficult to think about exercise in times of financial stress, but it could be possible to carve out time to participate in a softball league or to make time to walk in nature, or the public park. Cutting out the cable channels can make for creative ways to spend that time. Some of the poorest people are the most active in service to others, because of what giving gives back to them.

It seems obvious that TLCs have to potential to help people lead better lives. When we’re healthy and we know something is good for us, we usually do it. But how do we implement these when depression or anxiety are present? In that case, those TLCs begin to feel like burdensome “shoulds”—and most everyone has resisted doing something just because we should, even if not depressed.

Depression & Anxiety Make Implementing Healthy Behavior Difficult

Depression and anxiety make change feel impossible to achieve. A well-meaning partner will say, “Just get up an hour earlier and go for a walk.” But to a depressed person, that’s a monumental effort. Getting up and exercising when you are feeling fatigued and lethargic is no simple thing. Sleep, as well as energy, is affected by depression; bouts of insomnia, for example, can lead to too much daytime sleeping, making sufferers look lazy to their families. ”Just get up and go,” the non-depressed person might say; “don’t lie around all day.” And while this may be absolutely the right thing to do, the depressed person has no “get up and go.”

Likewise, someone with social anxiety has trouble engaging in activities that will bring social connection. Avoiding people becomes the norm, thereby limiting potential rewards that come with socializing. For the depressed or anxious, not doing what they know they should be doing leads to self-incrimination and shame, worsening both conditions.

How Psychotherapy Can Help

Psychotherapy can help. During the first appointment, psychologists take a history that includes past and current relationships, educational and employment history, and family background. We also ask about current and past medical problems, medications, and use of substances. It is imperative to take this history to understand how the various life factors are impacting the current or “presenting” problem, as we call it.

Of course, while psychotherapy can begin the dialogue, the difficult part for many is implementing TLCs. What gets in the way of exercise, eating well, and taking time for you? If relationships are difficult, how are you contributing to that? Are you engaging in retail therapy or overindulging in drugs, alcohol, or other substances? An important component to any therapy is to look at what is working and what is not—and then taking responsibility for making changes in your life. Good therapy is not just about saying “Uh huh, you poor thing.”

Including the eight lifestyle behaviors in your life will undoubtedly help you feel better, use fewer psychiatric medications, and live life more fully, but if getting there from where you now feel like climbing Mt. Everest, then consider finding a good psychologist to help you.