Search Results

Exposure and response prevention may be enough to treat OCD. Exposure and response (or ritual) prevention (ERP) alone is as effective as ERP with psychiatric medication. Exposure homework compliance is extremely important for treatment success. It's important to continue ERP until a client is confident that they can manage their OCD on their own. People who struggle with obsessive-compulsive disorder (OCD) experience intrusive thoughts accompanied by urges to engage in repeated behaviors to ward off something bad from happening or to relieve distress. For example, someone might check that their front door is locked when they leave so often that they are late for work, and they may jiggle the door handle so frequently that they damage the hardware. The treatment with the most research support for OCD is exposure and response (or ritual) prevention (ERP). In ERP, people learn to trigger obsessive thoughts and resist the urges to engage in compulsive behaviors or rituals. In the example above, someone might practice turning the lock once and walking away no matter how strong the urge they feel to return and double-check. There are different therapy models for guiding exposure. Traditional exposure focuses on symptom reduction, while newer models with strong research support, such as acceptance and commitment therapy and inhibitory learning, do not. Psychiatric medication—mainly antidepressants—is also an effective treatment for OCD. Psychiatric medication tends to reduce the intensity of OCD thoughts and urges. When clients come into treatment for ERP for OCD, a frequent question they ask me is whether they should also be on medication. My response has been that ERP is effective with or without medication and that ERP may be even a little more potent than medication alone. My recommendations were based on a meta-analysis Cuijpers and colleagues published in 2013. As that study is over 10 years old, I was excited when I came across a more recent study from 2023 by Wheaton and colleagues asking similar questions. The researchers wanted to know whether ERP alone or ERP-plus-medication is more effective. Study design For this study, the researchers combined data from two separate clinical trials of ERP for OCD. One study involved participants who were already taking an antidepressant before beginning ERP. The other study consisted of participants who were not taking medication before or during ERP. As both trials used the same manualized ERP protocol, participants in each received comparable versions of ERP for OCD. The manualized ERP protocol involved 17 sessions, meeting twice weekly with phone calls between sessions. As once-weekly sessions without phone calls are more typical in most practice settings, this manualized version of ERP is more intensive than one is likely to find in the community. One limitation of this protocol is that most OCD therapists use as many sessions as needed for clients to graduate treatment rather than limit treatment to 17, as in the study protocol. What did they find? Participants appeared to improve about equally as well from ERP, whether they were taking psychiatric medication or not. One important factor was what the authors called homework adherence. In ERP, people complete exposure exercises regularly—usually daily—between appointments. The researchers defined “homework adherence” as consisting of 3 parts: (a) quantity of practice (e.g., how often they engaged in exposure); (b) quality of practice (e.g., how well they engage in exposure); (c) and ritual prevention (e.g., resisting urges to engage in compulsions between sessions). Participants with higher OCD symptom severity and/or worse quality of life at the start of treatment showed less improvement overall. The researchers suggest these individuals may need more intensive treatment or more sessions than permitted in the study. As noted above, the study protocol was limited to 17 sessions of ERP. While 17 sessions may be enough for many clients, it's important to engage in as many sessions as necessary to work through relevant exposure exercises until someone can engage in daily life without compulsions. Consequently, limiting the number of sessions may mean treatment ends prematurely for some people. Here is one example where something that strengthens the integrity of a research study design is less applicable in a real-world setting. As I tell my clients, we will continue ERP until they are confident that they can manage their OCD on their own, without the structure of regular meetings. Conclusions This study supports what I’ve told clients all along: ERP is an effective treatment whether they are taking psychiatric medication or not. Anecdotally, if someone is struggling with ERP, sometimes psychiatric medication may help to reduce OCD symptoms just enough that they can better engage in exposure work. I want to stress another important conclusion of the study: how crucial it is that people complete ERP homework outside of session. Typically, an ERP therapist assigns daily exposure practice. For example, I might ask a client with health-related obsessions to spend 30 minutes repeatedly reading a triggering medical article (e.g., young people dying of cancer) each day between appointments until they can read the article more objectively and without engaging in compulsions. For someone afraid of accidentally hitting someone with their car without realizing it, they might practice driving through a heavy pedestrian area each day, perhaps on their way to or from work, resisting any urges to turn around and check that they did not hit someone. Regular and consistent practice is extremely important in ERP. I liken it to a musician practicing scales or a basketball player practicing free throws. Deliberate practice helps to reinforce learning so that people can respond more effectively in the moment, even under duress. As this study's authors note, improving homework adherence is an important target for improving outcomes in ERP. Brian Thompson, Ph.D., - Website - References Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds III, C. F. (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta‐analysis of direct comparisons. World Psychiatry, 12(2), 137-148. Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40. Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., ... & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behavior Research and Therapy, 108, 1-9. Wheaton, M. G., Rosenfield, B., Rosenfield, D., Marsh, R., Foa, E. B., & Simpson, H. B. (2023). Predictors of EX/RP alone versus EX/RP with medication for adults with OCD: Does medication status moderate outcomes? Journal of Obsessive-Compulsive and Related Disorders, 39, 1-9.

Is it true that people with borderline personality disorder can't change? Borderline personality disorder (BPD) is a condition characterized by emotional dysregulation. There is no quick and easy fix for BPD, although it can be managed with a number of different therapies. Contrary to popular belief, the prognosis for people with BPD is good, for those who are engaged in therapy. Borderline Personality Disorder (BPD) is a condition characterized by emotional dysregulation. There are a wide range of symptoms that differ across individuals, although the core traits of BPD include unstable personal relationships, fear of abandonment, an unstable sense of self, impulsivity , and self-harming behaviors. BPD is a chronic and debilitating disorder for sufferers, and often for those around them. Over five million people have been diagnosed with this disorder in the US alone, although the true numbers may actually be much higher. It can take a long time to obtain an accurate diagnosis, sometimes years or even decades. People with this condition are commonly misdiagnosed. BPD is often confused with bipolar disorder , ADHD , PTSD , anxiety , and depression , although it can be comorbid with these conditions. BPD is a complex disorder that is difficult to treat. In the past, many believed that BPD was untreatable, and lumped it together with harder-to-treat conditions, including narcissistic personality disorder (NPD) and antisocial personality disorder (ASPD). Even today, BPD is thought to have a gloomy prognosis. It’s often said that people with BPD “don’t change.” But is this true? Is there a cure for BPD? Unfortunately, there is no definitive “cure” for BPD. There isn’t a quick and easy fix, but there is hope. BPD can be successfully managed with a number of different therapies. Dialectical Behavior Therapy (DBT) is the first-line of treatment for BPD. (O’Connell, 2013) Developed by psychologist Marsha Linehan in the 1970s, who was herself diagnosed with BPD, DBT is an evidence-based psychotherapy that focuses on thoughts, beliefs, behaviors, and actions. It provides training in critical skills, especially mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation. There are other treatments too, notably cognitive behavioral therapy (CBT) and transference-focused therapy (TFP). There is no targeted medication for the condition, although antidepressants and mood stabilizers are often used in conjunction with therapy. In some severe cases, sufferers might require a period of hospitalization. Marsha Linehan herself revealed that she had been institutionalized as a teenager for self-harming and suicidal behaviors. What are the success rates for treatment? Contrary to popular belief, the prognosis for people with BPD is good, that is, for those who are actively engaged in therapy. In controlled clinical trials, DBT has been shown to be effective for reducing and managing symptoms with a success rate of 50-70 percent. (Álvarez-Tomás, et al., 2019) DBT has also been shown to reduce hospitalizations, substance abuse, self-injury, and suicidal behavior. Heartening research suggests that up to 77 percent of people no longer meet the criteria for BPD after one year of treatment. Alternatively, some people notice a natural reduction in their symptoms over time. (Biskin, 2015) These results are promising, although the road to recovery isn’t always easy. Many people with BPD are unlikely to ask for help or are in denial about their condition. The treatment is most effective for those who want to help themselves, rather than those who are forced into therapy. The treatment can be difficult too, for both the patient and the therapist. A commitment to recovery is important and people with BPD must do the work to see positive results. The takeaway message is that BPD is treatable. With the right treatment, a person who has this condition can definitely change, which will drastically improve their quality of life. Karen Stollznow, Ph.D., - Website - References O'connell, B. and Dowling, M., 2014. Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. Journal of psychiatric and mental health nursing, 21(6), pp.518-525. Álvarez-Tomás I, Ruiz J, Guilera G, Bados A. Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies. Eur Psychiatry. 2019;56(1):75-83. Biskin RS. The lifetime course of borderline personality disorder. Can J Psychiatry. 2015;60(7):303-308.

Exploring the social influence on the brain signatures of self-esteem. The basis of self-esteem may be more related to others' opinions. Brain imaging reveals that lower self-esteem is linked to brain patterns more attuned to external opinions. If you have low self-esteem, it might be time to reflect on how much it is influenced by others' perceptions. What is self-esteem? Is it something related to how you evaluate yourself, or is it based on how others think about you? Well, there are numerous theories of self-esteem in psychological science, as well as criticism of the construct itself. While these theories often diverge on some points, they all share a common idea: in one way or another, our self-esteem is dependent on our social context and relationships (Stendel et al., 2024). In a word, what I will argue for here, is that our self-esteem is heavily influenced by two primary factors: a) our perceptions of how others view us, and b) the degree to which we depend on these perceptions. This idea isn't new. It dates back to at least 1902, when Charles Cooley, a prominent American sociologist, introduced the concept that our self-perceptions are shaped by our understanding of how others perceive us (Cooley, 1902). Known as the relational or interpersonal account of self-esteem, this concept was supported by research across various fields of psychology. Studies on the Social Aspects of Self-Esteem For instance, a research group led by Anne Reitz recruited over 1,000 teenagers to examine the relationship between their self-esteem and perceived popularity among peers. They found that an individual's sense of popularity within their social group was linked to increases in self-esteem (Reitz et al., 2016). Additionally, a 2020 meta-analysis on self-esteem and social relationships revealed a reciprocal link between the two. Positive social interactions tend to enhance self-esteem, while negative experiences can weaken it (Harris & Orth, 2020). The role of social media in shaping self-esteem has also gained attention in recent studies. For instance, Woods and Scott reported that social media use is often associated with lower self-esteem, primarily due to negative feedback and upward social comparisons stemming from online interactions (Woods & Scott, 2016). All these studies will not surprise a person familiar with Lev Vygotsky’s Sociocultural Theory (Vygotsky, 1978). His theory claims that human development begins at a social level (between individuals) before becoming internalized on a personal level (within the individual). This process, known as internalization, can be exemplified by a mother frequently telling her son he is a good boy, leading him to internalize this as "I’m a good boy." On a larger scale, consider how a person from childhood (who knows nothing about who they are) develops their self-concept through interactions, opinions, and expectations from others. Brain Scans Reveal Interesting Insights Recent brain imaging experiments have provided further insights into the social nature of self-esteem. Consistent research has identified the medial prefrontal cortex (MPFC) as a critical brain structure involved in self-evaluation (overview, Stendel et al., 2024). For instance, one study showed that individuals with lower self-esteem exhibit more intense MPFC activation in response to negative comments about them, whereas those with higher self-esteem show less activation (perhaps because they don’t care as much) (Somerville et al., 2010). Even more intriguing findings were published this week in the prestigious journal Communications Psychology. Using fMRI technology, researchers from the University of Oregon, led by Moriah Stendel scanned the brains of participants while they reflected on themselves and then the brains of other individuals while they reflected on the first person (Stendel et al., 2024). They discovered that individuals with lower self-esteem showed more similarity in MPFC activation patterns to those who thought about them, indicating that their brain activity is more aligned with others' opinions. Conversely, individuals with higher self-esteem displayed more independent brain activation patterns when others thought about them. In simpler terms, if you have low self-esteem, your brain is more attuned to others' opinions and even tends to mirror their brain activation. This study is important because it corroborates various existing theories, including Vygotsky's, and has potential implications for clinical research. Low self-esteem is a well-documented risk factor for numerous mental health disorders (e.g., Orth et al., 2009). It might be that in order to help individuals with low self-esteem, one needs to facilitate the separation of their self-perceptions from the opinions of others as an initial step in therapeutic intervention. What Does It Mean for You? Do you have high or low self-esteem? This might be a good moment to reflect on how much your self-perception is influenced by what others think of you or what societal frameworks you accept (e.g., “I'm pathetic because others had different expectations or hopes for me”). If you find that external opinions heavily impact you, it might be time to work on cultivating a more independent sense of self-worth. After all, developing your "unique brain activation patterns" and focusing on your own values can lead to greater personal growth. Nick Kabrél, MA, References Stendel, M.S., Guthrie, T.D., Guazzelli Williamson, V. et al. Self-esteem modulates the similarity of the representation of the self in the brains of others. Commun Psychol 2, 113 (2024). Cooley, C. H. Human nature and the social order. (Charles Scribner’s Sons, 1902). Reitz, A. K., Motti‐Stefanidi, F., & Asendorpf, J. B. (2016). Me, us, and them: testing sociometer theory in a socially diverse real-life context.. Journal of Personality and Social Psychology, 110(6), 908-920. https://doi.org/10.1037/pspp0000073 Harris, M. A. and Orth, U. (2020). The link between self-esteem and social relationships: a meta-analysis of longitudinal studies.. Journal of Personality and Social Psychology, 119(6), 1459-1477. Woods, H. and Scott, H. (2016). #sleepyteens: social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self‐esteem. Journal of Adolescence, 51(1), 41-49. Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes (Vol. 86). Harvard university press. Somerville, L. H., Kelley, W. M. & Heatherton, T. F. Self-esteem modulates medial prefrontal cortical responses to evaluative social feedback. Cereb. Cortex 20, 3005–3013 (2010). Orth, U., Robins, R. W., Trzesniewski, K. H., Maes, J., & Schmitt, M. (2009). Low self-esteem is a risk factor for depressive symptoms from young adulthood to old age. Journal of abnormal psychology, 118(3), 472.

The need to feel safe is a core driver of human behavior. Every person has a deep drive to feel safe. We are anxious when we feel unsafe. In the physiological state that accompanies feelings of safety, your body refuels, regenerates, and heals. Sustained stress breaks down your body—mentally and physically. There are many ways to create a sense of safety—and heal. The need to feel and be safe is a deep driving force of all life, including human. In the physiologic state ushered in by feelings of safety, the body refuels, regenerates, builds muscle and bone, empties waste products, fights off foreign invaders well—and the organism thrives. Consider newborn babies who are cared for and nurtured by their family, especially their mothers. They not only thrive as children but have better health in adulthood. A chaotic, even abusive upbringing predicts a harsh life. Many chronic mental and physical health issues occur that shorten lifespan and also markedly compromise quality of life. Raised in such an environment, a child cannot reach his or her full potential—so much energy is consumed by trying to survive. Consider a young plant in rich soil with plenty of sunlight and water. Compare it to the same plant in poor soil, limited sunlight, little water. It may even look like a different species. Feeling unsafe When we don’t feel safe, the state of threat is reflected in our physiology, with mechanisms of flight or fight (the stress response) turned on and preparing us for action. We’ll do whatever we can to restore a sense of safety. Feeling unsafe drives many, if not most destructive behaviors. Feeling trapped can cause us to react aggressively to resolve the situation. Anger represents the body’s powerful last-ditch effort to regain control. Since the most stressful problems are ones we can’t solve, sustained anger turns into rage and destructive behaviors,. What's more, the wear on tear on body tissue resulting from a sustained stress response causes physical breakdown leading to chronic illnesses. Consider how many life situations are unsolvable. One of the deadliest and universal problems is feeling trapped by our thoughts. We can’t escape our thoughts. Suppressing unpleasant thoughts fires up the threat response even more than experiencing such thoughts. Suppression causes the hippocampus (memory center) of the brain to shrink1 and increases craving for opioids.2 Distracting we also fires up the immune system.3 Coping behaviors Addictions. Addictions create a sense of safety but only temporarily, so they are obviously not long-term solutions. Addictions are so destructive because they temporarily mask mental and physical pain, and pursuing relief is compelling. Power. An outcome of feeling chronically unsafe is the relentless pursuit of power in order to gain more control. It can’t and doesn’t work, but few of us are taught alternatives. Means of control can vary but they can infiltrate every domain of our lives and relationships with others. No one wants to be controlled, Every child has anxiety when they leave home to begin school. They want acceptance but also need to diminish fear. This plays out in forming cliques, excluding others, and overt bullying. Nothing enhances our feeling of control more than by gaining power in some way. A study compared the physiological profile of bullied students versus bullies. 4 Researchers measured an inflammatory marker called C-reactive protein (CRP); it’s often measured to detect infection and also indicates a stressed, overactive immune system Bullied children were found to have elevated CRP levels compared to those who hadn’t been bullied. Even more disturbing was that CRP levels in bullies were lower than the norm. There is both a social and physiological reward for power. How all of this plays out in adulthood isn’t subtle. Why give up power and control when anxiety is the alternative? Every child has a strong need to be accepted, yet it gives him or her more power (and self-esteem) to reject someone else? This is an endless loop. Self-esteem. Much of our self-esteem is programmed in by people telling us who we should be or not be. The voices in our head become as concrete as any object. The “stories” are essentially cognitive distortions. Pursuing self-esteem as a means of feeling better about ourselves can't work; it is a gross mismatch of the unconscious brain overpowering the conscious brain. We expend a tremendous amount of energy building up our ego and then spend endless efforts defending it. Factors such as stress, past trauma, and perfectionism affect the frequency and intensity of self-critical thoughts. Since we cannot escape our thoughts, feeling safe can be challenging. What can you do? Learn to be emotionally vulnerable, which is at the core of meaningful human relationships, although there is no reward in nature for being physically vulnerable. The capacity for language creates emotional pain in humans that is much more complex than in other mammals. Since emotional pain is perceived similarly to physical pain, it hurts. Anger, as unpleasant as it is, is powerful, addicting, and masks being vulnerable. Anger is an attempt to create a sense of emotional safety—but no one around you feels safe. How do people learn to be vulnerable who are used to dealing with a lot of anger? Dynamic Healing. The need to pursue dysfunctional behaviors dissipates as you address anxiety, the source of sustained threat physiology (anxiety). You cannot control survival reactions but there are numerous ways to regulate them. Creating the condition of safety physiology—what I call “ dynamic healing ”— allows you to feel safe, connected, and relaxed: Dealing with life’s challenges in a manner that has less negative impact on your nervous system. Regulating the state of the nervous system—from threat to safety, hyperactive to calm. The focus is on learning skills to create cues of safety. It is embodied healing rather than “self-help." David Hanscom - Website - References 1. Hulbert JC, et al. Inducing amnesia through systemic suppression. Nature Communications (2016); 7:11003 | DOI: 10.1038/ncomms11003 2. Garland EL, et al. Thought suppression as a mediator of the association between depressed mood and prescription opioid craving among chronic pain patients. J Behav Med (2016); 39:128–138. 10.1007/s10865-015-9675-9 3. Cole SW, et al. Social Regulation of gene expression in human leukocytes. Genome Biology (2007); 8:R189. doi: 10.1186/gb-2007-8-9-r189 4. Copeland W, et al.” Childhood bullying involvement predicts low-grade systemic inflammation into adulthood.” PNAS (2014); 111: 7570-7575.

Ways to protect yourself from emotional mind games. There's a difference between casual phrases and patterns of manipulative behavior. Gaslighting can have serious consequences and leave emotional and psychological pain. Recognizing gas lighters can save you a lot of emotional pain and doubt. It’s concerning how certain psychological terms can quickly become fixtures in our vocabulary. Not only that, but they are also often misused. While it’s good to talk openly about our mental health issues, it’s problematic when those conversations are based on misinterpretations of psychological concepts—and even worse when we apply these terms to everyone we dislike. In our effort to destigmatize mental health, we may inadvertently make things worse. We are beginning to convince ourselves that we are all victims and therefore defective, broken, or mentally ill. Sympathy and validation have become the new currency of social interaction, often traded without scrutiny or reflection. While well-meaning, this trend risks perpetuating a culture where labeling someone as toxic, abusive , or dysregulated becomes an easy way to dismiss disagreements or discomfort. "Gaslighting" is one of those terms that has become overused and prevalent in passionate discussions. I notice how often the person using it doesn’t truly grasp its meaning when accusing others and describing themselves as victims of it. In this post, I’ll address a series of myths around the term to answer questions such as: What exactly is gaslighting, and how does it differ from a simple misunderstanding? Can gaslighting be both malicious and unintentional? Exploring these questions can help us understand this concept more accurately, distinguishing truth from fiction. This can help us understand the nuances of psychological manipulation in personal relationships, provide clarity in therapeutic contexts, and empower individuals to recognize and address manipulative behaviors. Myth: Gaslighting is simply denying something you said or did. Reality: While denial can be a part of gaslighting, it’s not the whole picture. Gaslighting is a pattern of behavior —not an isolated event—in which individuals attempt to confuse someone else’s sense of reality, memory, and judgment. It involves repeated actions, such as flat-out denying things that were clearly said or done, minimizing or dismissing the other person’s concerns as unimportant or exaggerated, turning the tables to make the other person feel responsible, and fabricating stories or twisting events to create doubt and confusion. Myth: Gas lighters are always conscious of their manipulation. Reality: Gas lighters are generally deliberate in their attempts to manipulate and deceive others. They may not be fully aware of the harm they cause because they may not very reflective or empathic people. They do gaslight with the intention to exploit vulnerabilities, using sensitive information such as identity, children, or self-worth as tools for control. It’s also possible that some individuals may unconsciously use similar tactics to avoid responsibility or conceal their insecurities. These individuals may not fully qualify as gas lighters in the strict sense, as their actions lack the frequency and intentionality that define true gaslighting. Myth: Gaslighting is always a deliberate act. Reality: While gaslighting is often intentional, there is nuance to this understanding. Abusers may not always be fully conscious of their tactics but are typically aware of the intention and the effects—such as causing confusion or shifting blame. Some abusers may rationalize their behavior, believing they are entitled to act as they do. Over time, gaslighting can become a learned skill, reinforcing the gas lighter’s sense of power when their manipulation succeeds. Myth: Gaslighting only happens between romantic partners. Reality: While gaslighting frequently occurs in romantic relationships, it can also manifest in other contexts, such as friendships, family dynamics, professional environments, and even interactions with strangers. Once an individual becomes adept at gaslighting, they may apply these tactics across various relationships, embedding them into their personality and behavior. Myth: Anyone who uses certain phrases is a gas lighter. Reality: Phrases like “You’re imagining things” or “You always blow things out of proportion” can be tools for gaslighting, but their use alone does not define the tactic. The key to identifying gaslighting lies in the context, intent, and frequency of these phrases. Are they being used to manipulate and control, or are they occasional remarks made during heated arguments? Isolated instances of such language do not qualify as gaslighting. Myth: Self-gaslighting is possible. Reality: The term "self-gaslighting" is a misnomer. Gaslighting requires an external manipulator. While you may doubt your own memories or perceptions, this is not the same as someone deliberately manipulating you to question your sanity. Myth: Gaslighting is always obvious. Reality: Gaslighting is often subtle and insidious. When a person is aware of the effects of the tactic, they may become skillful at it, making it difficult to detect, especially in the early stages of a relationship or when the victim has already internalized self-doubt, making it harder to recognize manipulative tactics, or when they "trust" the individual who is quietly abusing them emotionally. Myth: Gas lighters don’t know they are lying. Reality: True gas lighters lie blatantly and deny things even when presented with clear evidence. We are assuming that a gas lighter is an emotional abuser. They may dismiss evidence as a mistake, fabrication, or something else entirely, but they are not doubtful of their lies. They may also "forget" events or rewrite history to suit their narrative, making the victim question their perception and lose confidence. Recognizing Gaslighting If you’re questioning whether you have been gaslit, here are some signs to watch for: You constantly feel confused and off-balance. You find yourself apologizing frequently, even when you’ve done nothing wrong. You second-guess your decisions and doubt your own judgment. You question your memories, perceptions, and interpretation of events. You’re afraid to express your feelings for fear of being ridiculed or dismissed. If you notice someone engaging in behaviors that resemble gaslighting, consider addressing it directly. Calling them in gives you the opportunity to understand the intention behind their actions and to determine whether the behavior is truly manipulative or a misunderstanding. It also allows them the chance to recognize the harm their actions may cause and take accountability, which can potentially lead to growth and change for both parties. Gaslighting is a serious issue, but you don’t have to either remain a victim or assume you are one if there’s no real reason for it. Trust your instincts: If something feels off, pay attention to patterns of behavior rather than isolated incidents. Stay grounded in reality by practicing objectivity, reflecting on your triggers and trauma responses, and seeking support when needed. Avoid engaging in conversations that consistently leave you feeling confused or diminished. And remember that you deserve relationships that empower and uplift you. Take the first step by believing in yourself. Antonieta Contreras - Website -

Your dream's setting might help you find peace. Look at all the aspects of a dream, as the solution to the problem often sits in plain sight. The location where a dream occurs may point you to the solution to your current issue. How you feel in a dream can be the quickest way to connect to the subject of a therapeutic discussion. Hanna dreamed she was searching frantically for her friend in a retreat center. While her panic and anxiety evoked a waking-life situation in which she felt overwhelmed and resentful, the dream’s location offered her the first step in making her situation more livable. The Dream In my dream, my friend Mary and I were at a retreat center. I couldn’t find her and began to look for her, going through hallways, into rooms, and into a dining area. I became frantic because I had no idea where she was. Later, I was sitting and talking with (actor) Liam Neeson. I saw my mother at another table, and I was relieved to see Mary sitting in a wooden chair by the door to the outdoors. The Discussion I began by asking Hannah, “How did you feel in the dream? Was your panic immediate? Hannah answered, “No, I didn’t feel frantic at first. I was frantic and upset while searching for her, and this was the feeling I woke with, even though I found her before I woke up.” Needing more detail, I inquired, "Can you describe a retreat center for me?" Hannah offered, "A retreat center is a place where people go to get away from their daily lives and stresses, to experience fun or learn something. Often, the retreat center is located in a country setting with a calming sense of nature all around.” Wondering about Hannah's associations with Neeson, I asked, "What comes to your mind about him? Do you like him?" She responded, "Liam Neeson may be a symbol of a traumatizing time in my life because I know he lost his wife in a tragic accident." I then asked, "What kind of person is Mary?" Hannah replied, "My friend Mary has been a victim of bad luck in life and overprotective parenting that stunted her growth and potential. Despite this, she is very compassionate, intelligent, and kind. She lived as she chose to rather than living up to her actual potential or parental expectations. Mary has suffered silently but always remained in good cheer and has been a very supportive friend." Hoping to help Hannah connect the dots, I asked, "Can you connect Liam to a traumatizing time in your life or a recent trauma ? Since your dream story is about Mary and you describe her as a victim, do you also feel victimized recently?” Hannah made some connections. "You are spot on, Layne. When I described Mary as a victim, I felt like I had just given you a description of myself. "My mom passed on four years ago from Alzheimer's disease. I see myself as a victim because I was her sole caretaker. My father was in complete denial of my mother's illness , and my sister, with legal power of attorney, couldn't face the changes and stayed away. Neither of them offered me any help whatsoever. "Your questions resonate deeply with me, not only because I feel like a victim, but also how I associate Liam Neeson with trauma. Being the sole caregiver for my mom was a trauma, and I am now inside another trauma every day. "I’m again the sole caregiver, this time of my father. My unresolved anger with my sister has me feeling resentful and hopeless. The toll of caregiving has been enormous, but very little compassion comes back to me. "In these last few days, I have been anticipating how I will have to deal with their house after my father passes away, including repairs he refuses to address. "Finally, I can't leave out how, at 63 years old, I am victimized by myself as I struggle to get out of the loop of negative, hopeless thinking and find purpose besides taking care of people. I am very kind to others but not to myself." I shared some of my impressions. "Thank you, Hannah, for your honesty. I am impressed with your great feelings and great responsibilities, all sitting under an umbrella of disappointment, frustration, and anger . Mostly, I’m struck by how overwhelming it all is. "This is where I see a strength inside your dream. Without discounting the difficulty, let's look at some achievable solutions. To get yourself out of the loop of negative, hopeless thinking, think of a relatively small, practical action you can do for yourself. "Think of Mary at the end of the dream, sitting by the door that leads to the outdoors. A small ‘retreat’ to nature might help in alleviating your daily suffering. “Perhaps the 'retreat center' offers a concrete suggestion. How would you feel about taking a break at an actual retreat center? Follow your own dream's advice." Smiling, Hannah responded, "I am already in motion on this idea. There’s a retreat and yoga center very close to my home. I am definitely going to begin the process of having my sister, who has power of attorney anyway, step in here or arrange for a caregiver for a 10-day break for myself." What We Can Learn All parts of a dream lead back to the dreamer. In Hannah’s dream, her friend Mary brings her right back to her own sense of victimization. Her emotions also evoke her waking-life feeling of anxiety, which she anticipates will only worsen after her father’s death. However, other parts of this dream show movement in a positive direction. The final image of her friend seated by the door to the outside offers a vision of greater freedom. The dream’s setting at a retreat center provides a concrete path toward taking greater care of her own mental and physical health. Hannah’s experience shows how all parts of a dream can help us analyze its meaning and then allow us to access more of our own thoughts and feelings as we resolve difficult issues in our lives. Layne Dalfen, - Website -

Early intervention and appropriate treatment are essential for managing PTSD effectively. Raising awareness of post-traumatic stress disorder, or PTSD, is crucial to eliminate stigma around it and support the recovery and well-being of those affected. Spreading awareness also plays a vital role in encouraging timely treatment. Early intervention and appropriate treatment are essential for managing PTSD effectively. When people are aware of the signs and symptoms, they are more likely to seek help promptly, reducing the risk of prolonged suffering and potential negative outcomes. There are many effective treatment options and resources available to help those with PTSD. What Is PTSD? PTSD is a mental health condition that can develop in individuals who have experienced or witnessed a traumatic event that posed a serious threat to their life or safety. It can also occur when someone learns about the unexpected death or severe injury of a loved one. It is estimated that 8 million people in the US are living with PTSD. Many sufferers of this disorder are not getting the help they need . One of the reasons why many individuals with PTSD do not seek treatment is due to the stigma surrounding mental health conditions. Some people may feel embarrassed about their symptoms, while others may not even realize that what they experience is PTSD. Lack of awareness and understanding about mental health issues can also contribute to the underutilization of treatment resources. PTSD Symptoms The symptoms associated with PTSD can be distressing and may persist for months or even years after the traumatic event. Individuals with PTSD may feel stressed or anxious even when they are not in danger. PTSD symptoms fall into four categories: Flashbacks: Re-experiencing the trauma through intrusive distressing recollections of the event and nightmares, and experiencing the same bad feelings you felt when the traumatic event took place. Flashbacks are sometimes caused by a trigger. Avoidance: Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma. Hyperarousal: Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered. Being on high alert or on guard without being in any danger. Negative changes in beliefs and feelings : Individuals with PTSD may develop a negative outlook on themselves, others, or the world in general. They might blame themselves for the trauma or feel a pervasive sense of guilt. They may also experience self-doubt, feelings of worthlessness, a loss of trust in others, a loss of interest in activities and hobbies, and emotional numbness. Living With PTSD PSTD can have a significant impact on various aspects of a person's life. Here are some specific ways in which PTSD can interfere with daily functioning: School and work: PTSD symptoms, such as difficulty concentrating, memory problems, and intrusive thoughts, can make it challenging to focus on tasks at school or work. This can result in decreased productivity, poor performance, and potential difficulties in maintaining employment or pursuing educational goals. Relationships: PTSD can strain relationships with family, friends, and romantic partners. People with PTSD may experience irritability, anger , emotional numbness, or a sense of detachment, which can make it difficult to connect with others. The avoidance behaviors that often accompany PTSD can also lead to social isolation and strained interpersonal interactions. Everyday activities : Engaging in daily activities, such as going to the grocery store, attending social events, or participating in hobbies, can become overwhelming for individuals with PTSD. Hyperarousal symptoms, like hypervigilance or an exaggerated startle response, can make them feel constantly on edge and anxious, even in non-threatening situations. This may lead to avoidance of certain places, people, or activities, further impacting their quality of life. Emotional well-being : Living with PTSD often involves experiencing high levels of stress, anxiety , and emotional distress. Individuals with PTSD may struggle with managing their emotions, leading to frequent mood swings, feelings of sadness or hopelessness, or an inability to experience positive emotions. These emotional challenges can further contribute to difficulties in daily life and overall well-being. Chronic stress associated with PTSD can have adverse effects on physical health. It can weaken the immune system, disrupt sleep patterns, increase the risk of developing cardiovascular conditions, and exacerbate other pre-existing health issues. The good news is treatment is effective and accessible. PTSD Treatment Options—It's Never too Late Early Intervention is best, but effective treatments are available for PTSD, even if you have been experiencing symptoms for an extended period. With the right support and therapies, it is possible to alleviate the symptoms of PTSD and regain control over your life. Remember that you are not alone, and many resources and support systems exist to help individuals with PTSD. Over the years, advancements have been made in understanding and treating PTSD, leading to improved therapeutic approaches. It's essential to remember that everyone responds differently to treatments, and what works for one person may not work for another. If a previous treatment did not provide the desired results, it's certainly worth considering trying again or exploring alternative treatment options. According to the National Center for PTSD, trauma-focused therapy gives a person the a good chance of recovery. Other therapies and certain medications can also be effective. Trauma-focused psychotherapies: Treatment that focuses on the memory of the trauma and its meaning. Thinking about a traumatic memory may initially evoke feelings of fear or discomfort. However, when done under the guidance of a trained professional , this specific form of therapy can be highly beneficial for individuals with PTSD. This type of therapy includes cognitive processing therapy (CPT), prolonged exposure therapy (PE) and eye movement desensitization and reprocessing (EMDR). By addressing and gradually confronting the traumatic memories, thoughts, and emotions associated with the trauma, individuals can begin to heal and experience relief from PTSD symptoms. Research has shown that trauma-focused therapies can lead to significant improvements in PTSD symptoms as measured by the Clinician-Administered PTSD Scale (CAPS). CAPS is considered one of the gold standard assessments for measuring the severity of PTSD. The long-term outcomes of these treatments are encouraging. A study examined individuals who had received PE or CPT and followed up with them five to ten years later. The results showed continued improvement in CAPS scores. Approximately 80 percent of the study participants no longer met the diagnostic criteria for PTSD. It is important to note that individual responses to treatment may vary, and these results are based on research studies. However, they do provide hope for individuals seeking effective treatment for PTSD and highlight the potential for significant and lasting results. Medications: Certain medications, such as selective serotonin reuptake inhibitors (SSRIs), can be prescribed to help manage PTSD symptoms. They may be used in conjunction with psychotherapy or as a standalone treatment. Other therapies and interventions : In addition to trauma-focused psychotherapies and medications, alternative or complementary approaches, such as mindfulness-based therapies, acupuncture, yoga, support groups, and art therapy may also be beneficial for some individuals in managing their PTSD symptoms. These interventions can provide additional avenues for healing and self-expression, and they can be used as adjuncts to traditional therapies. In Summary If you or someone you know is struggling with PTSD, I encourage you to reach out to a mental health professional who can provide appropriate guidance and support throughout the healing journey. Working with a trained professional can provide essential support during this process. Therapists who specialize in trauma understand the complexities of PTSD can conduct a comprehensive evaluation, consider your individual circumstances, and recommend the most appropriate treatment approach for your specific needs. It may involve a combination of therapies or a tailored treatment plan. Remember, recovery from PTSD is a process, and it can take time. It's important to have patience and be open to trying different treatments until you find what works best for you. With the right support and treatment, it is possible to find relief from PTSD symptoms and regain a sense of well-being. Diane Roberts Stoler, EdD - Website - Book References: Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (Eds.). (2009). Effective treatments for PTSD, Second Edition. New York, NY: Guilford; DeAngelis, T. (2017, November 1). PTSD guideline ready for use. Monitor on Psychology, 48(10). https://www.apa.org/monitor/2017/11/ptsd-guideline; Resick, Patricia A: Nishith, Pallavi: Weaver, Terri L: Astin, Millie C.: Feuer, Catherine A. Journal of Consulting and Clinical Psychology, Vol 70(4), Aug 2002, 867-879. doi: 10.1037/0022-006X.70.4.867

How they can guide you with a trauma-informed approach. Post-Traumatic Stress Disorder (PTSD) is a severe mental health condition that affects millions of people worldwide. It can arise after experiencing or witnessing a traumatic event, causing individuals to struggle with intrusive thoughts, emotional distress, and avoidance behaviors. Seeking professional help from a qualified PTSD therapist is essential for effective treatment and healing. Understanding PTSD and Its Impact Before delving into the qualities of a competent PTSD therapist, it is crucial to understand the impact of this condition. According to the National Center for PTSD, about 6 percent of the U.S. population will experience PTSD at some point in their lives. Trauma whether resulting from combat, sexual assault, natural disasters, or other traumatic events, can significantly disrupt an individual's life, relationships, and overall well-being. Gender plays a significant role in PTSD prevalence, with women being more susceptible to developing the condition compared to men. About 8 percent of women and 4 percent of men will experience PTSD at some point in their lives. This disparity is attributed, in part, to the types of traumatic events more commonly experienced by women, such as sexual assault, which can leave lasting psychological impacts. Furthermore, veterans face a higher risk of developing PTSD compared to civilians. Among veterans, those who have been deployed to war zones are at even greater risk of experiencing PTSD. The exposure to combat-related trauma intensifies the likelihood of developing this mental health condition. The Power of Trauma-Focused Treatment Trauma-focused treatment has shown promising results in helping individuals with PTSD. This evidence-based therapy focuses on addressing the specific issues related to trauma, using various therapeutic techniques to help clients process their traumatic experiences and develop coping skills. According to many studies conducted between 1995 to 2013, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been found to be highly effective in reducing PTSD symptoms in children and adolescents. What is Trauma-Focused Cognitive Behavioral Therapy? Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based therapeutic approach designed to help individuals, particularly children and adolescents, who have experienced trauma and are struggling with the psychological effects of traumatic experiences. TF-CBT combines elements of Cognitive Behavioral Therapy (CBT) with trauma-focused interventions to address the unique needs of trauma survivors. The main goals of trauma-focused cognitive behavioral therapy are to: Address Trauma-Related Symptoms: TF-CBT aims to reduce and manage the distressing symptoms associated with trauma, such as intrusive thoughts, nightmares, flashbacks, and emotional numbing. Promote Emotional Regulation: The therapy helps individuals learn effective strategies to cope with overwhelming emotions and regain a sense of emotional control. Enhance Safety and Coping Skills: Clients are taught healthy coping skills to manage stress and anxiety while enhancing their sense of safety and empowerment. Foster Cognitive Restructuring: TF-CBT works to challenge and reframe negative beliefs and thoughts related to the traumatic event, promoting more adaptive and constructive thinking patterns. Address Trauma-Related Grief: The therapy provides a safe space to process feelings of grief and loss associated with traumatic experiences. Improve Interpersonal Functioning: TF-CBT aims to improve communication and problem-solving skills, enhancing the individual's ability to form healthy relationships and connections. The TF-CBT process typically involves the following components: Psychoeducation : Therapists educate clients and their families about trauma and its impact on mental health to enhance understanding and reduce stigma. Relaxation Techniques: Clients learn relaxation and grounding techniques to manage anxiety and stress. Exposure and Desensitization: Gradual exposure to trauma-related memories or triggers is used to help individuals process and cope with their traumatic experiences. Narrative Development: Clients are encouraged to share their trauma narrative in a safe and supportive environment, promoting understanding and acceptance of their experiences. Safety Skills: Therapists help clients develop safety plans and strategies to manage potential triggers and crisis situations. Qualities to Look for in a PTSD Therapist Specialization in PTSD Treatment: Look for therapists who have specialized training and experience in treating PTSD and trauma-related disorders. Such therapists are well-versed in evidence-based interventions and understand the complexities of trauma recovery. Empathy and Compassion: PTSD therapy requires a high level of empathy and compassion. A therapist who creates a safe and non-judgmental space allows clients to feel heard and supported, fostering a strong therapeutic alliance. Trauma-Informed Approach: Seek therapists who adopt a trauma-informed approach in their practice. This approach ensures that the therapist recognizes the potential impact of trauma on a person's life and provides care that is sensitive to their unique needs. You can read more about this in the section below. Collaborative and Client-Centered : A competent PTSD therapist will involve the client in their treatment plan, collaborating on achievable goals and personalized strategies to aid in their healing journey. Up-to-Date Knowledge: PTSD treatment methods are continually evolving as research progresses. Look for therapists who stay current with the latest developments in trauma-focused therapy. What is a Trauma-Informed Approach? A Trauma-informed approach is a way of understanding and responding to individuals who have experienced trauma in a manner that is sensitive, compassionate, and supportive. This approach acknowledges the widespread impact of trauma on mental health and recognizes that trauma can affect individuals in various ways, leading to potential long-term consequences in their lives. The key principles of a Trauma-informed approach include: Safety: Ensuring physical and emotional safety is a top priority when working with individuals who have experienced trauma. Creating a safe and supportive environment helps foster trust and healing. Trustworthiness and Transparency: Being reliable and transparent in all interactions builds trust between the individual and service providers. Trust is essential for clients to feel comfortable sharing their experiences and seeking help. Choice and Empowerment: Allowing individuals to have a sense of control and autonomy in their treatment and recovery process is empowering. Giving choices and respecting their decisions promotes healing and self-esteem . Collaboration and Mutuality: A trauma-informed approach emphasizes collaboration between service providers and clients. It recognizes the client as an active participant in their healing journey and promotes a sense of mutuality. Cultural Sensitivity: Understanding and appreciating the cultural backgrounds of individuals are essential in providing effective and respectful care. Being sensitive to cultural differences prevents traumatization and fosters inclusivity. Understanding Trauma's Impact: Service providers strive to understand the potential impact of trauma on individuals' lives, behaviors, and coping mechanisms. This understanding helps in developing appropriate interventions. Avoiding Re-traumatization: Ensuring that environments, interactions, and interventions do not inadvertently re-traumatize individuals is a core principle. Avoiding triggers and maintaining a trauma-sensitive approach are vital. Conclusion When dealing with PTSD, choosing the right therapist is paramount to the recovery process. Seek professionals with specialized training in PTSD treatment, empathy, and a client-centered approach. Remember, healing is possible, and you deserve a life filled with happiness and well-being. Rubin Khoddam, Ph.D.

Cutting-edge techniques can improve PTSD symptoms. The amygdala detects threats and helps us deal with danger. Patterns of brain activity called theta rhythms are important for fear memories. Theta rhythms in PTSD patients are linked to symptom severity. Changing amygdala theta rhythms significantly reduces PTSD symptoms. Fear is an adaptive emotion that helps us cope with threatening situations. Deep within the temporal lobe of the brain is the amygdala, the most studied brain area involved in fear. The amygdala uses all kinds of information from outside and inside the body to help us interpret and react to danger. The Amygdala and Fear Upon detecting a threat, the amygdala causes reactions that prepare us to deal with danger. For example, if you hear a sudden noise behind you when walking alone at night, you might experience a racing heart, changes in breathing, and tension in your muscles. These amygdala-dependent reactions enhance the body's readiness to respond to the threat. The amygdala is also important for making fearful memories. When an individual encounters a threatening situation, the amygdala forms a memory of that event, tying together all the parts of the environment, such as sounds, smells, and visual features. These fearful memories help us adapt and make faster decisions in the future. However, in some people who have experienced trauma , the amygdala is hyperactive, which is believed to cause maladaptive behavior that is distressing. An example of this is the symptoms associated with post-traumatic stress disorder (PTSD). Amygdala Activity Rhythms Associated With Threats Distinct types of brain rhythms are associated with various cognitive functions, including fear memory. In the amygdala, a type of rhythm called theta is thought to help the amygdala process information and form memories. Most of what we understand about amygdala theta rhythms comes from animal studies because measuring it requires placing electrodes into the brain. Theta has been recorded in the amygdala of patients with epilepsy undergoing neurosurgery; however, whether theta might be different in PTSD patients is poorly understood. Finding out how theta functions in people suffering from PTSD could be critical for developing new treatments. Recording Theta in the Human Amygdala In a remarkable study, Gill et al. recorded amygdala rhythmic activity as part of voluntary clinical trials for PTSD. Patients were implanted with electrodes into the amygdala, and brain activity was recorded for more than one year. Activity in the amygdala was recorded while patients looked at unpleasant images and listened to audio recordings of their own trauma-related memories. Patients also self-reported their symptoms using a questionnaire, and the researchers were able to link amygdala theta activity changes to times when PSTD symptoms were at their worst. Neuromodulation of Amygdala Theta for Treatment of PTSD The authors then applied an innovative technique known as closed-loop stimulation to change amygdala function in the hope of reducing PTSD symptoms. In closed-loop stimulation, the surgical device was used to stimulate electrically the amygdala when theta was detected. Remarkably, using this treatment strategy for one year led to significantly reduced severity of PTSD symptoms as well as reduced amygdala theta activity during aversive stimuli. Future Directions Admittedly, this is an invasive approach that requires neurosurgery and careful monitoring of patient health. Other clinical trials in PTSD patients are underway that are using non-invasive neurofeedback with functional MRI to downregulate amygdala function during trauma recollection. While this neurofeedback technique is showing promise for giving patients control over amygdala activity, it has yet to reduce symptoms significantly when compared to control subjects. Nonetheless, further work using these types of approaches is called for and necessary to help the millions of individuals suffering from PTSD. Jonathan Fadok, Ph.D., - Website - References Gill, J.L., Schneiders, J.A., Stangl, M. et al. A pilot study of closed-loop neuromodulation for treatment-resistant post-traumatic stress disorder. Nat Commun 14, 2997 (2023). Zhao, Z., Duek, O., Seidemann, R. et al. Amygdala downregulation training using fMRI neurofeedback in post-traumatic stress disorder: a randomized, double-blind trial. Transl Psychiatry 13, 177 (2023).

Personal Perspective: Are we doing more harm than good? There is a widely held belief that a preparatory phase is needed before PTSD treatment. There is no research comparing phase-based treatment directly with trauma-focused treatment. There is evidence that treatment works better when not delayed by a coping skills phase. The popularity of phase-based therapy for PTSD may be a training issue. Although there is no controlled research supporting the idea that patients need to be prepared to start evidenced-based treatments (EBTs) like cognitive processing therapy (CPT) or prolonged exposure (PE), there is a widespread belief among therapists that a preparatory phase may be beneficial or even necessary. Phase-oriented approaches consist of at least two parts, one phase in which some type of stabilization is provided, particularly with skills to increase emotional regulation or coping skills, followed by a trauma -focused treatment. A meta-analysis of phase-based programs found considerable improvements over time, but most studies examined did not have control conditions or used only waitlists/supportive counseling and not direct comparisons to EBTs only. Therapists' beliefs in the readiness of patients may affect whether they are offered treatment at all. One VA study of readiness for a residential program was based on mental health directors and providers based on subjective judgments of stability, readiness to change, and skills to manage distress. However, they admitted difficulties predicting who is actually ready for treatment or for which kind of treatment. A study of community therapists’ attitudes toward learning CPT found that many therapists thought that phase-based treatments were necessary. Although beliefs changed with case consultation, those who maintained their preexisting beliefs were less likely to complete training. On the other hand, there is abundant evidence that EBTs like CPT or PE, without any introductory phase, are effective in reducing PTSD symptoms, even among those with comorbidities such as depression , dissociation , suicidal ideation, substance abuse , and personality disorders . Adding a preliminary stage to treatment may, in fact, delay treatment or result in treatment dropout. Some examples follow: De Jongh et al. (2016), along with 20 other authors, reviewed treatment guidelines for Complex PTSD (CPTSD). The focus was on the need for a stabilization phase before trauma-focused treatment. After a complete review of the available treatment research, they determined that in studies with stabilization only, the dropout rate was about 50 percent and did not differ in PTSD or affect regulation compared to waitlist conditions. There was no research comparing phase-based treatment directly to trauma-focused treatment only. The available research on trauma-focused therapy with CPTSD or child sexual abuse without a stabilization phase showed significant improvements and no adverse effects. De Jongh concluded that treatment guidelines for CPTSD that recommend a stabilization phase may risk patients being denied or delayed from effective evidence-based treatments. In a study of adolescents in Germany with a child sexual abuse history, Rosner et al. (2019) conducted a phase-based treatment including commitment and emotion management followed by cognitive processing therapy (CPT). The CPT was conducted intensively over four weeks. Although there was a slight improvement in symptoms during the first phase, there were large reductions in symptoms following CPT. This included significant effects on PTSD, depression, borderline symptoms , behavior problems , and dissociation by the three-month follow-up. Dedert et al. (2021) focused on the widespread use of phase-based approaches for veterans using actual VA clinic data from 778 veterans who sought treatment for PTSD. Clinic directors have reported adopting preparatory groups to increase readiness for evidence-based treatments (EBTs), typically CPT or prolonged exposure (PE), to improve coping skills and reduce no-shows. These preparatory groups included psychoeducation about PTSD symptoms and relaxation skills, increasing positive behaviors to reduce PTSD symptoms, along with cognitive restructuring and anger management. What Dedert et al. found was contrary to those expectations. Standard procedures for clinicians were to describe treatment options, recommending CPT or PE as first-line treatments with the most evidence (and later in the study period, EMDR), but suggested that any patients who had reservations about treatment be first enrolled in a ten-week preparatory treatment. A total of 391 veterans initiated preparatory treatment. Only 24 percent subsequently initiated one of the EBTs. A total of 530 veterans initiated an EBT without a preparatory group. Preparatory groups resulted in small changes in symptoms of PTSD and depression. When an EBT followed the preparatory group, there were also small decreases in symptoms. However, when EBT was started first, the treatment resulted in moderate to large decreases in PTSD and depression symptoms. Dedert's findings indicated that the preparatory groups did not increase participation in an EBT and that direct entry into an EBT worked better than treatment following the preparatory group. One question to ask, given the lack of evidence that a preparatory phase is either necessary or sufficient, is why phase-based treatments are so popular. One possibility is a lack of knowledge about these findings. Another is that therapists have their own fears about doing EBTs. In an article on therapists' "stuck points" (inaccurate beliefs) prior to training in CPT, the second most common (of 37 items) was “Clients need preparatory treatment before they are ready to deal with their trauma.” Higher levels of therapist stuck points and less reduction in stuck points during training resulted in a lower likelihood of completing training requirements and less use of CPT 12 months later. Perhaps more focus should be on training therapists so that patients are not denied treatments that work. Patricia A. Resick, Ph.D., ABPP, References Dedert, E. A. et al. (2021). Clinical Effectiveness study of a treatment to prepare for trauma-focused-based psychotherapies at a Veterans Affairs specialty posttraumatic stress disorder clinic. Psychological Services, 18, 651-662. De Jongh, A., et al. (2016). A critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 33, 356-369. LoSavio, S. T. et al. (2019). Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes. Professional Psychology: Research and Practice, 50, 255–263.

Finding gratitude for your grit, gifts, and ability to overcome. Complex PTSD, or relational trauma, can be tied to generational legacies of abuse, neglect, or abandonment. Without awareness, someone could believe that these kinds of generational burdens are their failings alone to remedy. Starting a "gratitude-for-myself" practice can remind someone of the grit, gifts, and changes they've created in this generation. Through this practice, someone can find some grace for themselves and for what they have "done differently." In healing from relational trauma or complex PTSD —a type of PTSD thought to arise as a result of extended or repeated trauma—we often forget or dismiss what it is we’ve been up against. And for some of us, it’s what we’ve been up against our entire lives. Generations of negative family patterns and relational woundings are our legacies. Sometimes we forget—or never were really aware—of our generations and generations of “burden loading”: burdens handed down to us, carried, compounded, and left unmitigated through our family lines—burdens like abuse , neglect, abandonment, or loss. These are wounds created through our families, communities, societies, and/or cultural and historical norms. When we forget that we carry these generational burdens, at our core we may believe all of the compounded shame, inadequacy, and powerlessness we feel is because of how we, alone, have “failed” to make our life different. Our individualistic society reinforces this notion. On a personal level, our sense of those perceived failings may include feeling horrified when we slip and sound or act “just like my mother/father.” Or they show up when we have a hard time taking a compliment or acknowledging our gifts because we’re loaded with secret shame. And often, we compare ourselves to others—or worse, we compare ourselves to an ideal self that will always elude us. So, we believe that to feel safe and sane and able to survive, we must go on a mission to get those “failings” under control. We get into perfectionism, consumerism, workaholism, or addictions—which makes perfect sense, because the non-conscious belief goes something like, “If I’m just smart enough, fast enough, rich enough, or numbed out enough, I will never have to feel 'that' again. No more of that vulnerability, that loneliness, that not belonging. I will get that handled!” We tend to rev up, and then double down on, our familiar strategies for control. When we’re in this revved-up space, I argue that it's good to consider pausing—and maybe pausing a beat longer to consider starting a gratitude practice. Here, I would offer a little different type of gratitude practice. It’s a gratitude-for-myself practice. You may start this practice by getting curious about how you might: Begin to find gratitude for what you have summoned in yourself to overcome, survive, and thrive. Get really specific. Look at the whole of your life. Write it down. What have you had to manage? What have you had to overcome? What have you done that’s been growth-producing, took courage, required a risk, or demanded perseverance? Acknowledge and honor what you now see written in front of you. Add to it. Share it with a trusted other. Seriously celebrate it. Allow yourself grace for your mistakes and shortcomings. Expect less of yourself. Slow down, just for a day. Strain less and see how things can maybe still work out. Identify ways—against all odds—you’ve broken patterns from previous generations. Ask what is your shame to bear, and what belongs elsewhere. What is truly your responsibility now? How have you successfully answered for it? Really appreciate that you are just one person trying to make a difference in a chain of unaddressed pain. With your children, acknowledge how you’ve worked to “do it differently” with them, to break the generational transmission. Consider what you’ve done in your larger family or community to bring healing. By even being willing to be aware, you’re doing your part for those who follow. One of my clients said at the end of a session, her eyes open in surprise, “I didn’t realize how much I’ve been handling all my life. I’m not depressed; I’m legitimately sad and tired, and I’m sort of proud of what I’ve done in spite of all of it.” In spite of a life full of loss and trauma, she found this understated appreciation for the grit and gifts and sea changes she has had to summon to create a life for herself. That self-gratitude is part of where healing compassion starts, both for oneself and for others. Go get it. Jennifer Lock Oman, LISW, BCD, - Website -

Identify the source of your challenges to get the right solutions. Generally, if one family member has ADHD , they’re not the only one. Some people with ADHD find their symptoms, such as forgetfulness or messiness, affect their relationships with other people. The ability to regulate emotions when they become intense is a skill that many people with ADHD struggle with. Unless you’ve been stranded on an island for the past decade, you’ve probably heard and read a lot about the phenomenon of adults getting diagnosed with ADHD . Many people age 18 and over feel like they have significant problems focusing, getting things done, procrastinating, and generally being efficient in their jobs and their personal lives. Many of these individuals have been successful academically; they may have even been honors graduates and high achievers. Their experiences look typical on the surface, but they say their life is a mess. Not to mention, social media has thousands of blogs, testimonials, and other resources about adult ADHD. There’s even a YouTube channel called “How to ADHD.” This post gives you questions you can ask yourself to help decide if you might have ADHD and benefit from a formal evaluation from a psychologist. 1. Do your symptoms disrupt your ability to function at work or at school? People often think they might have ADHD if the problems they have functioning are quite disruptive. Their struggles prevent them from being efficient, which means things take much longer than they should to complete. Many people hate their jobs because they feel like their responsibilities highlight the weaknesses they have in being efficient and organized. Or they get incredibly bored with their work, so they can’t always put their best foot forward. They may question their career choices or majors in college because they don’t feel motivated to complete tasks on time. 2. Do you struggle in personal relationships? Some people find their ADHD symptoms affect their relationships with other people. They may be forgetful, which annoys their friends or partner, they’re messy and disorganized, they talk too much or too loudly, or they constantly interrupt people. The quality of their relationships is therefore compromised by their challenges. Note: If similar problems are disruptive to your professional or personal life, it’s definitely time to seek support from someone with expertise in assessing and treating ADHD. 3. Do you experience intense emotions? The ability to regulate emotions when they become intense is a skill that many people with ADHD struggle with. They talk about losing control of their emotions, becoming reactive quickly, and being unable to calm down after getting really upset or excited. There are other mental health conditions for which this is also potentially an issue, but it’s much more common among people with ADHD than has been talked about in the research until recently. 4. Do other people in your family struggle with, or have they been diagnosed with, ADHD? You may not know if other people in your family have been diagnosed, so it’s worth having a conversation with a parent or sibling to find out more. There is a genetic component to ADHD, so it can run in families. Generally, if one family member has it, they’re not the only one. 5. Are you struggling with other conditions or circumstances that might mimic the ADHD experience? It is true that you could be one of those people who have compensated and functioned well, despite having ADHD that was overlooked when you were younger. It happens, and I do evaluations routinely with clients who meet the criteria, according to the DSM-5. But you may not know that there are other mental health conditions that affect focus, which can result in many of the other problems that we attribute to ADHD. Individuals with a history of trauma , for example, may exhibit some of the same cognitive symptoms, such as inattention, trouble making decisions, difficulty with organization, and trouble finishing things they start. These symptoms are also present in many people with depression and related mood disorders and anxiety. Additionally, individuals with chronic medical conditions, like thyroid disease and anemia, can also experience cognitive symptoms similar to those of ADHD. Sometimes people struggle with focus and disorganization if they’re overcommitted. Our society encourages us to be busy, to be involved in a lot of things, and to fill our days, but it’s possible to be too busy, and when this happens, it’s hard to focus on what is right in front of us. We have high expectations for ourselves and struggling to meet them may create an experience that feels like ADHD. Understanding the underlying source of your challenges is important because interventions, including medication, may change, depending on the reason for them. Getting to the bottom of why you struggle with these challenges needs to be investigated if they are becoming disruptive to the life you want to have. Talk to a mental health professional about your concerns, so that you can get the right answers. Carla Shuman, PhD - Website