Understanding the Difference Between Anxiety and Trauma

Welcome to the Anxiety Society Podcast.

We're your hosts, Dr.

Elizabeth Mackinbell and.

Cali Werner, both therapists and individuals that have navigated our own anxiety journeys.

Have you ever wondered how we became a society that is so defined by anxiety?

Tune in as we discuss, learn, and dive into what anxiety is, how we perpetuate it, and how we can stop it.

This podcast will be real, raw and unfiltered, just like the anxiety that plagues so many of us.

We are here to push boundaries, challenge the status quo, and deep dive into topics that are sure to make you uncomfortable.

If you're ready to step outside of your comfort zone and explore the unfiltered truth that will help you change your entire relationship with anxiety and get back to living your life, you're in the right place.

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And there's one thing that I need from you.

Can you come through?

Welcome back to the Anxiety Society Podcast.

This is my first episode back in a long time from maternity leave.

So I'm really excited and looking forward to today's episode.

Today's episode is one that I'm just really excited about because I love talking about the intersection of trauma, anxiety, so many other disorders, but also how to treat trauma.

So we are joined by an incredible clinician and colleague, Emily Weems.

So, Emily, thanks for joining us.

Thank you for inviting me.

I don't know if you know how you feel about this, but I like, geek out about trauma work and I think part of it is because I did my postdoc at the VA and learned a lot about trauma treatment.

But for me, trauma is something much like OCD that actually there's such great treatment for.

There is, and I love that like that when there's like really good evidence based treatment that we know works, that's when I just get so excited.

And I'm especially grateful because, because I was introduced to OCD treatment through meeting you in 2016 and learned about exposure therapy.

Then it guided me to go get trained in prolonged exposure because of Edna Foa, you know, creating that therapy.

And then that just opened the gates to like, well, I also want to get trained in cognitive of processing therapy, get trained in written, written exposure therapy.

So now it kind of, I feel like OCD work led me to now being trained in PTSD evidence based treatments that I love to do at OCD Texas.

And one of the things that, you know, we'll talk about later today is I, I think, correct me If I'm wrong, but it feels like PTSD diagnosis is really often comorbid with another diagnosis as well.

Yes.

I would say that it's very rare that you just see ptsd, and especially with teaching people.

And I was putting together a training on OCD and PTSD and concurrently treating them, and it's actually surprising that OCD and PTSD, when they occur together, almost 60% of the time, it's after or the same year that a PTSD diagnosis has been given.

And I say that, though, to also be careful because.

Because I don't want people wrongfully to assume that if you have ocd, it means that you have PTSD trauma or you had some.

And that's not in all cases.

But in cases where that is true, the OCD normally sometimes follows years later or in the same year as the traumatic event.

Totally.

Yeah.

And I've seen all ways, as I'm sure you have, right, where I've seen, um, a traumatic event, PTSD diagnosis and then OCD follows.

I've seen OCD and then a PTSD diagnosis later if there's trauma, and then, of course, OCD without.

And I know for myself.

It was interesting because when I was first showing signs and symptoms of ocd, my family was really preoccupied about feeling like I must have had a traumatic experience.

And I talk about this a lot that every clinician I go to was, like, preoccupied of, did something happen?

Like, were you sexually abused?

And I.

I remember at one point literally saying, do y'all want me to just tell you I was?

Because everyone KE asking, and I kept saying no, like, I wasn't.

Right.

And so it is important to know that OCD and a lot of diagnoses, they're not always better explained by something that happened previously.

Right.

But sometimes that can happen for sure.

So we want to assess and understand.

Is there comorbidity?

Is there not?

Because it changes treatment.

Right.

To degrees.

So we will hop in.

But before we do, I do not know if you have listened to our podcast, but we always start with an anxious moment.

So the anxious moment is an opportunity for us to just talk a little bit about our own anxiety and all of the above.

And I'll go first, break the ice for you, and then feel free to hop in and share yours.

But my anxious moment, and this has happened.

I have, you know, now four kids, which is wild.

But it's happened with my first two, and it's happening again now with the twins is I'm just feeling a lot of guilt that I don't feel as connected as I feel like I'm supposed to.

And I know this is a normal experience in the sense that, at least for me, Right.

I definitely didn't know it was normal with my first, because I feel like I felt that.

And I remember telling my husband, like, matt, I just don't feel as connected yet.

And he said, yes, you do.

You love them.

And I remember feeling so invalidated because I was like, I didn't ask if I love them, but, like, I'm telling you, I don't feel connected.

Something feels off.

And so anyways, it's just been causing me a little bit of anxiety because I feel like with the twins, it's been even more different because I have toddlers.

So I'm.

You know, you're.

You're with them, but then you're also with toddlers and running around.

So I'm giving them even less attention probably than I did my first or second kid when I didn't have other kids in the house.

But postpartum hormones and feelings where it's a lot, and you just.

You feel anxious about it and, you know, there's nothing you can do.

And, like, time will heal.

And it's one of those things that's kind of the best treatment.

Cause it's about, like, you just have to sit with it, right.

And just kind of say, okay, I feel that feeling, and I know that I'll move through that and it'll pass, but it's still not fun.

It's not.

It's definitely not fun at all.

I remember those times, even though I don't have twins or really little kids.

My anxious moment is also related to, like, parenting because I have two sons and one is in middle school, and now he's actually, you know, not that he didn't go through painful things, you know, in elementary school, but, you know, as you get older, you're, you know, as a parent, you're hearing about your child go through, like, feeling left out or feeling rejected.

And my anxious moment has to deal with, you know, having him bring.

Go through those things and not going into, like, fix it mode, but actually watching your child, like, go through difficult emotions and not wanting to just be like, get in the minivan and we're going to marble slab, or who said that to you?

And just actually feeling sadness or feeling loss or feeling scared or feeling worried and actually being with letting those emotions unfold instead of just letting them experience.

Them versus fixing them.

Yes.

And I've had to go into the bathroom many times and cry but still just be like, this is good for me.

This is good for him.

But it does bring up anxiety.

Cause you just have this sense of urgency of, I want this to go away, I want this to change.

How do I make someone feel better?

And luckily, though, working at CDI Texas and being like, okay, well, what did I just say to my patient this morning?

And I have to live that out too.

And I just feel so lucky to have my training and my background and the work I do to really help me in my hard moments too.

Yeah.

And I find.

I don't know if you find this, but I find that at times I can handle.

I was telling someone yesterday, I said, crying doesn't bother me.

And they were like, okay, you're weird.

But I was like, it really doesn't.

When babies are crying, I'm not anxious and triggered and stressed about.

It doesn't round me up.

And I think part of that is because of our work.

We watch people in high levels of distress and we have to sit with them.

I think, though, what I struggle with, and I'm curious if you do, is when I'm at home or when I'm in.

This happened to me yesterday.

I was having a conversation with someone who was sharing, like, a situation that they had had that was kind of a tough social interaction.

And I went into, like, giving them true therapeutic advice and feedback, like, just like being a therapist.

Right.

And then they kind of got more upset.

And I feel like my aunt.

I eventually was like, I'm sorry, like, what?

Where I had to realize sometimes people just want us to listen and they don't necessarily want us to, like, tell them what we think they could do different or better.

And that.

That is actually really.

Can be really insensitive and really invalidating.

And then it's like, oh, man, that was not my intention, but that is what I just did.

Do you feel that at home?

Like, is there times where you jump into therapy role with your kids?

Oh, yes.

Yeah.

I mean, I've done exposure therapy with my older son around, like, you know, getting shots and just did a full protocol.

It worked beautifully.

See, but sometimes it works.

And you're like, this is great.

Yeah.

Sometimes I'm like, oh, I just saved myself some money by not paying another therapist to do this.

But other.

I actually have the reverse where I feel like I.

Well, not with the kids.

With the kids, I immediately wanna go into therapy mode.

I'm like, oh, I know.

And I actually, now that I'm thinking about it, I did it with my younger Son too.

Cause he had some separation anxiety.

And we did a little, you know, worked on some behavioral therapy for that.

And you know, that nipped that in the bud.

So, yeah, I do teeter into that.

But I, I get told a lot by my kids that I'm a really good listener.

And I'm like, well, it's my, I learned that.

Yeah.

But I pull.

I notice when like other people in my lives that, you know, are my family members want me to like, go into therapy role and I just kind of like, no, I do that all the time.

I'm not going to do that.

This is like, that's going to create some like, confusion in our relationship.

And then I really dig my heels in and I'm like, I'm just going to like, listen to what you have to say and not.

But even if you're listening and not participating, if you're giving a great referral, that's better than anyone else.

Right?

Like, that's gold.

And that's where it's like, okay, I can't be your therapist.

And here's what I think would make sense for you.

And that's so valuable because you're, you know.

I think one thing I talk a lot about that I'm just so proud of, of so many people that I work with and I, that I know is that our ability to really see what's happening and give a good referral and the value in that.

You know, I think so many people want me to fix something or want me to give advice.

And I told someone recently, I was like, I don't, I'm not trained in that.

Like, I can't give advice, but I'm happy to even.

It was like for ADHD referral, I was like, I can give referrals, but like, I'm not like, well, what, what should therapy look like?

I'm like, that's not my specialty.

Like, I don't do adhd therapy with 8 year olds.

Like, I don't actually know.

Right.

But there's so much value in that too.

Right?

And us being able to be honest about.

I watch so many friends.

I was just telling you the other day, the last week about this thing I saw on Instagram where it talked about people having this inflated sense of confidence that shouldn't.

Around what.

And I think about this all the time where I have so many friends or family members that are like giving advice and giving feedback to people as though it's like the golden truth that's been evidence based for 30 years.

When I'm like, you have no idea what you're talking about.

Don't give them that feedback.

So anyway, sometimes a great referral is.

Yeah, it's a shortcut.

You're saving them, like, time, you're saving them money, going to these other different places and just saying, like, no, this is a path that you really should explore.

Yeah.

And why.

Right.

I think that's the big piece, too.

And that's what today is going to be all about.

So today we're going to focus on what does good trauma treatment look like?

How do you understand what trauma actually is?

One thing I want to make sure we talk about is the misuse of PTSD and the language that people often use around, oh, I have PTSD over that, or right when it's like, well, that's not actually what PT PTSD is.

And so I want us to definitely break that down, and I want to make sure that we instill lots of hope.

Because what you and I both know is that ptsd, just like a lot of other mental health disorders, is actually so treatable, and patients with this diagnosis can live a full life without it having to have a negative impact on them.

They totally can.

So today we're joined by an incredible clinician, Emily Weems.

Emily's a licensed clinical social worker at the OCD Institute of Texas and an adjunct instructor at Baylor College of Medicine.

She treats adolescents and adults diagnosed with anxiety disorders, ptsd, ocd, and OC related disorders.

She has a strong passion and dedication for working with individuals struggling with severe ocd, anxiety, and comorbidities in a residential and intensive setting.

She received her Bachelor's of Psychology from Loyola University New Orleans and her Master's of Social work from the University of Texas at Austin.

Emily completed her clinical training at Baylor College of Medicine, where she served marginalized communities with complex mood, anxiety, and personality disorders.

The part of the bio that's left out is you are one of the most incredible clinicians with this amount of empathy and compassion for your patients that is unmatched.

And I see that every day as I work with Emily.

But one thing that impresses me above all is your desire to learn.

And I always talk to you about that.

But Emily is always doing trainings, learning, and wanting to understand both modalities and our patients to best serve them.

So I'm so excited to just hear from you today and learn.

Great.

Yeah.

Well, thanks.

So let's hop in.

Let's start with trauma.

Can you.

How would you describe if someone said, like, what is trauma or what is ptsd?

How would you describe what trauma is versus what a PTSD diagnosis is?

And when does it cross that line?

Yeah, well, it's interesting because, you know, it used to be a very strict definition of, you know, trauma is where you feel like your life is being threatened in some way.

And now as like, you know, through social media and through just us talking to each other and sharing our experiences more.

Now this language has kind of moved around from talking about big T traumas, like with a capital T that kind of meet that definition of where your life, you feel like your life is in danger or someone that you love's life is in danger.

And this other idea of trauma with a little T where kind of all go through difficult things in our life and both of these things can lead to having trauma reactions.

And it really tips over into being PTSD when it meets these very specific criteria.

And for ptsd, for that criteria to be met, you have to be having four clusters of symptoms.

And those four clusters of symptoms are you have to be having experiences of re experiencing.

So when they talk about re experiencing, they meet flashbacks, nightmares, intrusive memory, memories.

Another cluster of symptoms is negative alterations in your mood and in your thoughts or your cognition.

So that's normally when someone's having a lot of guilt, a lot of shame, they're feeling detached from people.

They might be having a lot of feelings of like horror or anger.

So kind of changes in their mood and also changes in their thoughts about themselves, about others, about the world.

And then another cluster of PTSD symptoms is these changes in like your startle response.

Hypervigilance.

We call these kind of like hyperarousal symptoms.

And then the last one is one of the most important ones is avoidance.

A person with PTSD will have emotional avoidance where it's like, I just don't want to feel those feelings.

They'll just really stuff them down.

They'll have cognitive avoidance, or they may have cognitive avoidance where they're like, I can't think about that.

And so they'll really distract themselves.

Or physical avoidance where they're, you know, they see something on tv, maybe they have Law and Order on and the plot is around sexual assault, so then they'll immediately turn it off.

So avoidance can look many different things.

But normally for people to meet that like, kind of definition or diagnosis of ptsd, they have to have met those criteria.

And that's not to say that people who have some of those clusters of symptoms wouldn't benefit from some trauma related treatment.

They probably would.

And most of the cases that I've worked with here, they maybe didn't meet full criteria for a PTSD diagnosis, but we were just above that threshold and they did benefit from some type of trauma related treatment.

So I think that we wanna be careful.

That calling when you have ptsd, it's a very specific constellation of symptom and also something that's like people kind of wrongly assume is that if you've had a traumatic event, you will automatically, yes.

I wanna talk about that.

And that's just completely false.

And in all of my trauma trainings and looking at all the data, it's actually we think like, oh, if you, if 10 people have a traumatic experience where maybe they're a victim of a crime, all 10 people will develop PTSD.

And that's just not tr.

More.

It's a much.

I'm not going to throw out a statistic, but it's definitely less than half because really PTSD is a disorder of non.

Recovery.

Yes, yes.

So the way I was described this, that has always stuck with me since grad school is if you think about just this traditional bell curve, right?

If you really think about a bell curve, the way trauma often works is that people experience a traumatic event, right?

We can all experience a similar traumatic event.

And you hit that top of that bell curve in the sense of like the way it impacts you, the responses you have.

However, most people naturally recover from that traumatic event, right?

So they're able to like, they, they experience trauma responses, they have difficulties.

Maybe for some people it's a couple hours, a couple days, a couple weeks.

But most people actually naturally recover where those that receive a PTSD diagnosis, they get stuck in the recovery, right?

So if you think about that bell curve, they're kind of stuck somewhere at the tip or, you know, close to it.

However, what I love, what we're gonna get to talk about today is that treatment can actually get them unstuck and allow them to recover and make it down that bell curve.

And to me, that was always.

I loved drawing that out for patients and letting them see that so that they knew.

Because I think a lot of people come and think, I'm gonna feel like this forever, right?

I'm always gonna feel this, like I can't watch a show when I can't live my life and I can't talk to family and do these things that are triggering for me where that's actually not the case at all.

No, not at all.

Yeah.

So I want to talk for a second back about Big T, little T.

So can you get a PTSD diagnosis.

Now if you don't meet that older school criteria of life threatening events.

Well, right now the way the DSM is written is it still hasn't changed that criteria.

So in my practice I'm normally putting like unspecified trauma and stress related disorder.

If it doesn't meet that, that criteria.

And we're still doing some evidence based like trauma treatment, whether that's.

And so how are you, what language are you using with the patients?

Are you saying things like, you know, you, you live with trauma, you've had a trauma experience, you are diagnosed with a trauma disorder versus ptsd?

Yeah, I will say to really validate that, just because it doesn't meet this criteria of like a life threatening event doesn't mean that you don't have these trauma related symptoms and that this is, this is affecting you.

Because a lot of people too, if they don't meet, and even people who do meet criteria for ptsd, they're like, well, but other people have it worse.

My thing's not so bad.

And that's really unhelpful.

That doesn't help the recovery process.

So I think that some people who don't meet full criteria for ptsd, if you kind of give them that education that you can still benefit from a trauma related treatment, a trauma based treatment, even if you don't have full blown ptsd.

All the research, you know, with the caveat that all of the research was done with for people who did have a diagnosis of ptsd.

So I kind of just educate them of like, you know, I think this would be helpful given, you know, these symptoms that you're presenting with.

Do you want to see if this is, you know, start this work and see how you do with it?

Especially when I'm trying to assess if they would benefit from a trauma based treatment.

I'm basically looking for, do they have avoidance that is maintaining some of these trauma reactions?

All of them do.

And do they have trauma related cognitions that are really affecting and keeping them stuck?

Can you give an example of that?

Yeah.

A trauma related cognition is if they're have thought like have beliefs that if I hadn't had worn that outfit, I wouldn't have been sexually assaulted.

And then normally what follows from that is I can't trust myself, I make bad decisions and then that trickles down into all their parts of their life where they start doubting.

Well, I need to ask everybody before I make a decision because look what happened to me.

And so they just start to have this complete breakdown of self Trust and their judgment, and that just starts to affect everything in their life.

And a lot of black and white thinking can happen, too, in this arena, right?

Yeah.

I remember working at the va, I remember working with a veteran, and we were talking about kind of the trust continuum, right.

And how everybody has a different level of trust.

Right.

I would give my sister access to all my bank accounts and never worry, but I would not give her.

I might not give her a secret because she might tell a lot of people, and that's great.

I still trust her immensely, but I still have different levels within that, where oftentimes I would see individuals with PTSD unable to have that kind of distinction or discrimination.

Exactly.

It's like, I can't trust anybody.

Like, everything is dangerous.

People are always out to get me.

I'm always gonna, you know, at risk of dying or getting hurt or that sort of thing.

So very, very black and white it can be.

So let's start with the misuse.

So I was just thinking about this because I'll share my own journey again, but breastfeeding is really hard, and I kind of struggle and hate it at the same time.

And I cannot tell you the amount of women the past couple weeks when I'm like, yeah, that's what I'm struggling with.

Have said, like, oh, don't say that.

I have PTSD from breastfeeding.

And that's clearly a misuse of ptsd, right?

Like, you're using that inappropriately.

And some of them do have, like, even if it's little, a small trauma response to it, different ways, right?

You're going through postpartum, you're feeling a certain way.

And so I'm always curious of, like, how clinically, you know, so I'm not as worried about it with friends.

I just kind of laugh, right?

I mean, it's like, when.

What's the right place or time?

But clinically, I do see a lot, lot of misuse with patients.

Like, I will see a lot of patients saying, oh, I have PTSD from my last treatment experience or my last.

And of course they can, right?

If it meets certain criteria.

But often they just mean it was a bad experience or I've heard a lot of people lately saying, I have PTSD from having ocd.

And I'm like, well, that's an interesting.

Right.

But I.

I get what you mean, which is it's cost you a lot of life.

It's been really detrimental, right?

It's had a negative impact.

But I would not say that would meet PTSD criteria.

So how do you talk to patients about that?

How do you help patients distingu between, wow, I can see that this has been really hard for you, and you've had a really hard experience.

And let's talk about the difference between a PTSD diagnosis and something being difficult.

Yeah, I mean, that's exactly what I do where I really kind of normalize.

Like what I hear you saying is that, you know, this was something that blindsided you.

It turned your world upside down very much like when we have a traumatic experience and that, you know, you're reeling from this event.

And I, you know, want to be sure that you understand what is true ptsd, in case there's some doubt that you're like, I think I might struggle with ptsd.

And normally once in a while I'll explain what PTSD is.

They're like, well, yeah, I don't have ptsd.

Got it.

So I think just kind of like pausing for a minute and be like, whoa, whoa.

Well, let's check in about this, because.

If they do, we want to know that too.

Right?

We want to be treating that.

Yeah, if they do have that.

But I think just basic education can really help that.

And, you know, like you said, people are using this as like buzzwords and just trying to like a way to like, really express themselves or like really get a point home instead of.

And they're just using that as like a fill in word.

Totally.

No, that.

That makes total sense.

So trauma.

So somebody comes into your office and well, let's back up first.

So one thing.

Dr.

Bruce Perry does a lot of work in childhood trauma, and I love his work and I've read a lot of his books.

And one the things Dr.

Perry had mentioned before that really set home to me as he said something about, you know, when trauma is slow dosed, we give people a chance to recover.

And most people have a lot of slow dosing of trauma in their life.

Right.

You have different incidences that are traumatic and different things that you go through, whether it's the death of a loved one.

Right.

Different things that create these kind of trauma responses.

But for most people, they recover.

And a part of that is because hopefully it's slower dosed.

Right.

It's not.

You just get bombarded with 15 traumatic experiences at once.

It's the slow dose.

And in those instances, often people build up what we identify a lot as resilience.

Right.

That, okay, like, this was tough.

They make it through and then they kind of feel good, they feel empowered.

They were able to come out on the other side.

And they can do that effectively throughout their life.

Because we're all going to have different incidences and events that happen that create a trauma response.

However, when it's not slow dose.

So it's either one of these really big T's, right.

That would meet criteria, or individuals grow up in certain home like environments or certain situations or political climates or even, you know, countries, slow dosing isn't offered.

Right.

Or isn't a possibility.

And so I'm curious of like how much you see that of, you know, okay, you know, this individual like didn't really have a chance to recover from that last traumatic event or incident before they had another one.

And does that kind of create a stronger chance or likelihood that they're going to develop these negative responses to trauma versus that, that positive resilience that we hear people talking a lot about?

Well, I think that I see that most.

This reminds me of like my time when I was at Baylor College of Medicine when I worked a lot with people who were pretty much like our underserved populations, dealing with a lot of poverty, dealing with a lot of just crisis on a week to week basis.

Housing, misplacements, all this stuff.

Yeah, Housing, healthcare, multi generational families, having to care for like great grandparents or for you know, your sister's K.

And I think that that was where I saw a lot of what we kind of look like, what we kind of see as like complex trauma or complex PTSD where they're just kind of, there's this onslaught and they're not able to build any resiliency.

They're really in like fight or flight mode.

And it's very those folks.

It was really sad cause I would be meeting so many people who were like in their 60s and 50s that clearly have had lived their lives with full blown PTSD and just suffering and struggling through it.

Most of the people that I see now in the work at OCDI Texas is people who had not all the time, but a singular event and then they really weren't able to deal with that event because either they had other comorbidities or it just kind of the OCD kind of followed and it just created this conflagration of mental health suffering.

I have worked with some folks who had grew up in a really, really abusive home and they also had co occurring OCD that seemed to kind of serve as a coping mechanism.

But then they also parts of their OCD were completely separate.

And that's where we kind of have this understanding of these dynamic presentations where you think of two circles, and they're kind of like intermediate, intertwined, like a Venn diagram.

And then you have.

There's also PTSD and ocd, where they're just two separate circles and they're away from each other and they're just completely not connected.

And those are the lex.

Complicated cases, but still, both of those cases are treatable.

Yeah.

And I think about.

There was a case once that I was working on that had.

There was a ton of contamination rituals, and particularly in the shower.

Right.

Lots of different cleaning and contamination rituals.

And the person was really, really, really struggling.

And we didn't.

It wasn't assessed until later or at least disclosed that actually those were a response to a sexual trauma.

Right.

A lot of the cleaning behaviors were actually better explained as a sexual trauma response than an OCD ritual.

And so this is one of the reasons why, as clinicians, it is so critical, even if a patient shows up and appears to have certain symptoms from the outside, that we're really assessing for everything.

Right.

And.

And even not just ptsd.

Right.

But there can be other stuff going on.

Sometimes there's a thought disorder.

There's.

Who knows, like, you know, what went on if we don't assess.

But you can't just say, okay, this is what I see.

I'm going to treat.

It's like, what exactly is going on?

But in that case, there definitely was a trauma, and there was definitely PTSD that needed to be addressed.

And there was OCD as well.

Right.

But they did.

Those circles definitely collided compared to being totally separate.

Yeah.

And what I love about this work is you have to be.

I'm always telling myself in session, like, what assumptions am I making?

And just go back and just clarify.

Yes.

And I remember I was in a consultation group with Mike Hetty, and he was like, telling us.

He's like, guys, when someone is checking something, telling you, like, oh, I'm doing these checking behaviors, you know, you want to ask them, like, well, how many times are you leaving?

Open your gate.

Because you want to make sure, like, do they have, like, a, you know, like, actual not closing their gate problem?

Because we just kind of, you know, especially being, you know, an OCD therapist, I'm just like, you could see OCD everywhere if you.

Totally, totally.

Yeah.

And I'm so appreciative of people in our community and the OCD therapist community who are really working to show that, like, compulsions, repetitive behaviors overlap in so many diagnoses.

And you have to really do a good functional assessment around that.

And just understand that.

Exactly.

Functionally, sometimes the behaviors are not a big deal.

It's when they're disruptive.

Right.

But I always think Matt checks our locks every night and he does his little round in our house.

But it's funny because he leaves stuff open all the time.

And I'll go downstairs to get water, and I'm like, oh, he didn't close the blinds or didn't close these shades or whatever.

And.

And it's funny because I'll say to him the next day, oh, you didn't.

He's like, oh, are you sure?

I'm like, yeah, I'm sure.

I had to go close it.

He's like, oh, okay.

Right.

But it's very different.

Like, there's been a couple times where I'll wake up saying, hey, I don't think you closed the pool gate.

And I get a lot of anxiety about that, having toddlers.

Right.

That I'm like, we have to make sure it's closed.

Ours is like an automatic on one side.

And Matt will be like, okay, I'll deal with it in the morning.

And that's so different than someone with ocd.

When it's an OCD behavior.

If I have an intro, like a thought of did I close the pool gate or not?

There's zero chance I'm gonna keep sleeping and wait till the morning to check.

Right.

Like, I am going to go wake up and go downstairs, check it, maybe double check, triple check if it's an OCD behavior.

And so that's where this assessment is really important.

Yeah.

Just because someone says, oh, they're checking, or if someone comes in and says, you know, I recently was in a car accident and I'm having some flashbacks, that can be normal.

So let's talk about how long did the symptoms have to be and what would make you say, okay, do you actually meet criteria for PTSD versus this is actually a normal response to just being in a car accident?

Yeah, that's a really good question.

And so.

So in the dsm, what we have now is acute stress disorder.

And so that really captures, like, the first month or so after you have a traumatic experience.

And I was able to see this firsthand because my family was in a car accident and my husband was the driver, and he was definitely experiencing acute stress disorder.

And so right at the 30, 40 day mark, I was like, okay, this is when I'm gonna have to really put my foot down and be like, hey, you need.

We need to go get evaluated.

You need to get some help for this experience you went through and it was just like so illuminating to me to see after around week five, week six, just the natural recovery.

Isn't that wild?

Yeah.

But it can happen.

Yeah.

And it was actually.

And knowing what I know about how does PTSD heal and how does somebody recover from it?

It made a lot of sense because he had to be talking to insurance a lot about what happened and he hated it.

It was really, you know, annoying.

But he was really forced to go over the event.

Yeah.

He was doing built in exposures.

Yeah.

And he wanted to get the money from the insurance.

So kind of.

Well, I think about it even with death.

Right.

One of my best friends just recently lost her dad.

And even watching like individuals with, you know, obviously it's a terrible experience and grief is so hard.

But you watch them going to the funeral, there's just going to the bank, Having to change things, having to constantly deal with new stuff, it's not fun.

And it feels like you're bombarded.

At the same time, you're like, this is kind of built in exposure therapy.

Right.

If you don't avoid it that you're having to, it's forcing you to process.

And even she even said to me the other day, she's like, it just feels like you can't.

Even when you're like, okay, today we don't have to talk about it as much.

Like something new pops up or someone calls or there's another bill that shows up that you have to deal with.

And yes, that's hard.

And of course you'd want to avoid it.

At the same time, as a clinician, I'm like, it's kind of good that you're having to continue to kind of process and work through.

But of course it doesn't feel good to you.

Right.

No one wants to have to process difficult things.

We would love to be able to avoid and suppress them, but that's what keeps you stuck.

So let's hop into the most important piece, which is treatment.

And so, you know, I was trained in cognitive processing therapy and prolonged exposure at the va and I had some pretty good criteria back then about why and when you might use one modality over the other.

But I would love to hear, I know things have changed.

I know there's some more evidence based interventions that are, have shown up in different ways.

But let's talk first about just, you know, I want to remind viewers and listeners that we, you guys hear us talking a lot about cognitive behavioral therapy and it being the most evidence based treatment for all Anxiety disorders, for OCD and for trauma.

And it is, right?

So remember, remember CBT is that umbrella.

That's an umbrella of therapeutic interventions that fall underneath it.

And so when we talk about PTSD treatment, it really all falls under the CBT umbrella, correct?

Absolutely.

For things that are evidence based, which.

Is all we talk about here.

So don't worry.

So there's lots of things people are selling, lots of, you know, shiny marketing, but at the end of the day, we recognize pretty much four modalities.

I might be forgetting something, but these are the four main modalities that the va, which really the VA is the leader in developing trauma based treatments.

And I'm going to follow whatever the VA is saying is evidence based because of the rigorous randomized controlled trials that they have to be doing in the last 10 years, years they've added.

To start with, it was prolonged exposure, which is an exposure based treatment.

It's a structured treatment that goes anywhere from 12 to 16 sessions.

We have cognitive processing therapy, which is a 12 session therapy.

Again, it can be shorter or longer.

And then we also have written exposure therapy, which is a five to six session, very short.

It's meant to be a short term treatment.

And so it's really great for folks who maybe they can't be going to therapy very often or it's just very accessible.

And then the fourth one is EMDR that is also offered by the va.

I'm not trained in emdr, but with the very little I know about it, all four of these are working off of the same theoretical understanding of exposure.

They're just going about it in some different nuanced ways.

But all of these are involving targeting, avoidance and trauma related cognitions.

Right.

And I will say, as someone who was trained in PE and cpt, but really had OCD background before I did that training, that was my specialty already.

It is also similar, Right.

I remember being like, oh, this is so easy.

Like, I was so anxious with my first cases and then I was like, oh, I could just grab this worksheet and figure this out on my own.

Because it makes a lot of sense if you theoretically, right.

If you are a cognitive behavioral therapist, which is what all of us are, and you're trained in behavioral therapy, it clicks and makes sense.

You're like, oh, yeah, I understand avoidance very well.

I understand how these things are keeping you stuck.

I understand why we need to actually face our fears and walk through them them in a way that makes sense versus trying to hope that we can avoid them throughout our life.

But they Keep showing up.

Yeah.

And that these treatments are all designed to help you feel natural emotions that have been kind of suppressed or not dealt with.

And we do that in OCD treatment of like, okay, let's actually lean in and let's allow whatever experiences, emotions, sensations to be a part of our experience.

Yeah.

100.

So it just like marries so well together.

I was so excited to be trained in PE and being in those trainings and hearing someone who didn't have an OCD background be like, oh, yeah, but is this gonna re traumatize somebody?

It was so hard not to be like, shh.

What are you saying?

And I love how my trainer responded in those moments.

Cause she was like, that is a myth that lots of people espouse.

And really.

That really speaks to you needing to work on your own discomfort.

But at the end of the day, the truth is.

And this is such a truth that I feel like, is I see every day in our population, you know what's hard?

Doing treatment.

Doing PTSD treatment is difficult.

But what is more difficult is living with untreated ptsd.

That's right.

And same with the retraumatization.

So I will say, I hear this all the time with OCD treatment, where people will say, well, why would you make someone do that?

Like, people without OCD don't have to think about that and don't have to do these exposures.

And my answer is, is that they're already thinking about it.

They're already triggered by it.

It's not like when I tell somebody, okay, I want you to let that thought come and be there and not do anything about it.

They never had.

Had this thought.

That thought is already in their mind.

Right.

They're already triggered by it.

And so, in fact, what I would say is that the re traumatization actually happens to them every day with untreated ptsd.

Oh, definitely.

Right.

The treatment isn't what traumatizes them.

It's the constant fear that they live in that is re traumatizing.

Right.

The avoidance they're engaging in, like, the current behaviors they do are what keeping them stuck, not treatment.

And it is.

It's such a myth.

And I.

I get it, though.

As a non behavioral therapist, a lot of people think, why would I want to purposely cause someone anxiety?

Right.

So I think about this like a.

It was like a year ago, I was reading Olivia one of the.

I don't remember what book, but it was a book that at the end it had a monster.

And it.

She said to me, this is right before bedtime, she's like, what is that?

It's like this big green monster.

Right.

She had never really seen one.

And my go to was to hide that it was a monster from her because I kept thinking, well, I don't want to, like, make her anxious before bed.

And I don't.

Right.

And I found myself saying, like, what am I doing?

Like, why am I trying to protect?

And, like, I'm just creating, like, by not saying, oh, that's a monster, and, like, making it a normal thing, I'm making it scarier.

Right.

I'm making it more triggering.

But again, that was my own response of I didn't want to deal with a bad bedtime that night.

Right.

Like, I don't want to be dealing with that anxiety.

And.

And that actually was promoting it for her.

And so just think about that.

That.

Yeah.

Oftentimes as clinicians or individuals, like, of course it feels scary.

Of course it can be difficult.

Yet if you're not willing to do that, if you're not willing to do an approach because you feel like, I wouldn't want to make somebody more triggered right now or make them more anxious right now, you do need to evaluate that, because when you're living with an anxiety disorder, even if it's ptsd, you need to be willing to let the patients be more anxious in the short term to have freedom in the long run.

Absolutely.

And I love how when I was trained in PE and cpt, they talked so much about this idea that.

That it's almost like with untreated trauma, you have food that just won't be digested.

And so really good trauma treatments, whether any of the ones that I listed, really help the person digest and put that memory to rest.

And it's really teaching them in all of these modalities that one, the memory is not scary.

It's not saying, like, oh, that bad thing didn't happen.

No, absolutely not.

But it's in the moment when that bad thing is happening, you just nerve, you know, like, your brain does not process it and sort it and integrate it.

When you have PTSD in a fashion that promotes healing.

And so really, with good PTSD treatment, you are helping that person digest and finally see that this memory can't hurt me.

It's not dangerous.

I can think about this, and it won't undo me and leave me in the.

The fetal position.

This, you know, I can think about this thing and, you know, have memories of it and see that that was then and this is now.

I always say, imagine if you get to a place where you can have thoughts, but they don't become triggers.

Right.

Or you have thoughts but they're not triggering.

Right.

You can't, we can't guarantee when you're watching a show or you're with family that you're never going to have a thought again about this trauma.

Right.

About this incident.

But the difference is if you don't have a trauma response, if you, if it's not triggering to you, if it's not activating, wow, that's, that's freedom, right?

That's when you've kind of shifted.

So when I was trained, it was pretty clear that the guidance was pretty clear that people could really choose, we would really give them, we would help educate.

This is what you know.

Obviously I was just trained in prolonged exposure and cpt, but now you might talk about all four.

These are the modalities, like which one makes the most sense to you?

And you really let your patients have the autonomy.

However, when I was trained, it was pretty clear that we were not recommending prolonged exposures for women of sexual abuse.

So women, sexual assault survivors, is that still the case?

And how does that.

Yeah, that's still the case.

That's really the only caveat that the research shows is that there's just this slight difference of like CPT being better indicated for women for sexual assault survivors.

But that's okay across the board?

Yeah, okay.

That's really the only difference that I have found in the research.

But I follow the same thing that you just said where I will just do a lot of informed consent of like, these are the different options I normally give.

I explain the different ones.

What are the, you know, if you don't like, you know, worksheets, you're probably not gonna like cognitive processing therapy if you struggle with doing homework in between sessions.

You know, PE and CPT have that written.

Exposure therapy doesn't.

So maybe we should choose that one.

But really kind of laying out these differences and then I normally give them some videos.

There's.

For people who are considering cognitive processing therapy, this American Life, a podcast, did an amazing episode of a journalist who was curious about this, who had a history of a traumatic event, did and recorded her doing cognitive processing therapy in this condensed, like two week fashion.

And so I will let people be like, if you really want to know what it's like, you could listen to this one hour podcast.

It is about a sexual assault trauma.

So it is pretty intense, but it does give you a real sense of like, this is what I would be signing up for.

And then normally I'll, you know, they'll come back to the next session and they'll say, like, okay, I'm leaning toward this and we'll start that.

Yeah, we'll hop in and start to.

And I'm so lucky that because working in a higher level of care and in a residential setting, I can really structure it where I can be doing OCD treatment for two sessions and then we do a session of whatever trauma based therapy we're doing and really, for lack of a better word, knock it out.

Right, right.

No, yeah, 100%.

And I think that that's gonna be my next question.

As you talked earlier about kind of differences, where it sounds like written exposure could be as little as five weeks on an outpatient session.

If it's five sessions compared to more traditional therapeutic interventions are more like 12 to 14.

14 to 16 weeks.

Right.

So three to four months is what we typically would expect on a traditional outpatient.

Well, what I want to talk about, which is my favorite part of PTSD and OCD treatment, is what patients can expect after.

You know, I think there is this myth and belief that I'm always going to live with ptsd, I'm always going to struggle with ptsd.

And same for ocd, same for anxiety.

And we know that that just doesn't have to be the case.

I was, someone was asking our interest the other day, and I was saying, like, I've had a lot of clinical interest, but my biggest passion project lately has been on the language that's used around recovery and the language that's used around.

I think we went like, too far where, as you know, obviously OCD and mental health disorders were super stigmatized that no one talked about em.

And now it feels like we've gone so far that a lot of people are identifying with their mental health disorder.

And that can actually become problematic in different ways.

If you start to believe it's always gonna be a part of me, I'm always gonna struggle with it.

And this was something, something I'll be candid about.

The VA that I struggled a lot with is I struggled when they would give my patients disability diagnoses because they would say, you're 100% disabled from your mental health disorder.

You're 75% disabled.

And patients would hear that as well.

I'm disabled from my PTSD and I'm never going to be able to work.

I'm never going to be, because that's how benefits and things were decided.

And a lot of it was based on this percentage of disability where I'd be like, no, like you are not disabled from your ill right now.

It feels like you are.

But treatment actually can get you to a place of full functioning again.

And so I just want to talk about what can people expect and what hope should they have for themselves or someone they know living with PTSD if they're able to get effective treatment?

Well, so the most recent modality I've been trained in is written exposure therapy.

And what's so interesting, what the data shows about that is after the, you know, the five sessions, six sessions and they'll take.

So the standard kind of measure for, you know, for trauma symptoms and for PTSD is called the PCL5.

And so any trauma based treatment you're doing, typically the protocol is that you are taking that measure with every session you're doing.

So it's expected that in the very beginning of your, of the trauma based therapy that you're doing, you'll see this like kind of, you know, increase in storage.

Yeah, kind of like a.

Because you're, you're, you know, avoiding avoidance, right.

Like you're going to see kind of like an increase in symptoms and then you're going to see this trend down.

And what's really interesting is like for written exposure therapy, for example, after you complete the formal therapy, they did a lot of, they followed up with them three months later, they followed up with them six months later, and it continued to trend down even further.

So there's this idea too that you don't have to be in formal therapy to still be seeing the effects and still be seeing that.

Wow, my symptoms are reducing even further.

And I would imagine a big piece of that is because hopefully they're outliving their life and not avoiding anymore.

And the more you look live and the more experiences you have, the more you continue to remind yourself and your brain, right.

That I can, I can have different experiences, I can have different thoughts and I don't have to have these cognitive distortions or these avoidance behaviors.

And I think like for people, you know, I totally get why people would be like, oh, you know, this is just the way that it is.

I just have to make peace with this.

There's.

This isn't going to change.

But the reality is when you go through, through one of these treatments, you're going to see most likely that going from a place of, oh, this feels like this happened yesterday to oh, this doesn't feel like this happened yesterday.

I'm able to see this for what it is.

My thoughts are not going to the extreme opposite end of it, but they're just being a bit more balanced.

And it's interesting that also.

So when you're in the midst of some really difficult thing happening to you, you're not really taking in information very well.

And it's so interesting to me when I'm working with someone on a trauma treatment and we're either, let's say we're doing CPT and we're doing one of the worksheets where you're taking one of the trauma related beliefs, like let's say going back to that example I gave, that if I had fought harder, this wouldn't have happened to me.

And when we're going through that worksheet together around that specific thought and we're just kind of talking about it, we're not going from like, tell me the memory from the very beginning to the very end.

They're just kind of talking about like, okay, well tell me, what are the things that you did do?

And they're like, wait a minute, I did fight really hard.

And like, oh, I did say no.

And those things, when they're not going through trauma based treatment, they're not really, like spending time thinking about that and going back to it.

And so as you start to like, you know, by the time we're done with that worksheet, they're like, well, I'm forgetting this piece of information.

And, oh, I just remembered this as well.

And that just starts to do a.

Little bit of a shift of like, giving more clarity.

Yeah, getting a lot more clarity.

And it's always surprising to me that they remember things that I was like, oh.

And they're like, yeah, like, I forgot about that or.

Or I didn't remember that piece of it.

Because when you are having ptsd, it very much hones in on very specific information.

And a big part of cognitive processing therapy, a question that you ask a lot throughout the therapy is like, what pieces of information are you focusing on with this tunnel vision?

And what are you putting less emphasis on?

So, yeah, I think that's really incredible when I'm always having to control my affix on, I was like, that's a really big piece of information of part of the situation that happened.

Right.

But because of the tunnel vision, they had these blinders on.

Right.

And it's so beautiful in therapy when you get to watch those come off.

And even with OCD treatment, even with anxiety treatment, you see people, I always call it, but I get to see them build trust in themselves again.

They have these beliefs that they can't do certain things or that they wouldn't be able to, or that would be too difficult, and they do it.

And you get to watch this, look what you are capable of, and look at the trust.

You get to rebuild with yourself.

And I think even with trauma treatment, it's very similar.

It is very similar.

I think that's where why OCD work and trauma really pairs very well, 100%.

So this has been so helpful, and I know that our guests will want to hear more, and I hope that we could do a second episode where we could talk more about specific case studies and how you walk patients through that and what that looks like as we end.

I just want to hear, like, why you love trauma work.

Like, if you had to put it in a sentence for somebody who really wants to hear a why you love it, but also, like, if they're considering treatment, why they might want to actually consider it or make that phone call.

I think I would say that everyone deserves to heal and that.

So, you know, many people are kind of grow up with beliefs that, you know, good things happen to good people, when really the truth of the matter is that we all go through really difficult things, and some of us go through truly horrifying things.

And I just think it's so important that we extend compassion to ourselves.

And I just love doing this work.

And it's very powerful to see someone start to not have what happened to them define the whole story.

That moving it from working with people in the beginning, where it's like, no, this is like 100 chapters of my life, and starting with trauma work, to see that they've moved it to one chapter or moved it to a footnote and just really kind of take back their power over their lives and their story and not have what happened to them be the defining factor.

So that's what really draws me to the work.

And the fact that you tangibly see people change is just like dopamine to me.

Oh, totally.

No, it is.

And it's.

It's.

It.

I think that I will never forget my first.

My case at the va.

I was doing a case of a female of sexual assault, and I was.

I remember thinking, like, I'm not qualified.

Like, I don't think I can do Right.

Like, and which actually tends to make you more qualified.

Right.

Because you're doing so much more studying, so much more work, consultation, all the things.

And I will never forget the first session or two, her saying, like, there's no way I can do this like I can't talk about it, I can't do.

And at the end, the freedom she had and her ability to talk openly about, about the experience, of course it was still a difficult experience and not something anyone would want to talk about, but it no longer had control over her.

Yeah.

And haunts you.

It didn't haunt her anymore.

And I just remember saying like, wow.

And for me, I think I just, when I do trauma work, I'm just reminded of how strong people are, you know, that they can walk through these horrible, like give know experiences nobody should have to face and come out with just such a clear perspective.

But again, this freedom, right, where it doesn't have to weigh you down, these traumatic experiences, well, of course they're not going to be, they're not good.

Right.

You don't have to ever want them or enjoy them, but you can get to a place where they no longer control you, they no longer haunt you.

Like that is freedom from trauma.

Yeah.

And I, I think just to end on like hope, now there's even more language and you know, talk around this idea of post traumatic growth and how like going through these experiences, you can actually come out with these like new understandings of yourself after going through, you know, a trauma based treatment.

Yeah.

No, I mean my favorite quote, I'll end with this is without our struggle, we wouldn't know our strength.

Yeah.

And of course we don't want someone to have a struggle, but if they're showing up at our office, they've already got something they're struggling with.

And when they work, walk through that.

Right when you.

But, but of course, to be able to do that, you guys, I just want to remind you, you have to be working with someone who specializes in this disorder or the disorder you're struggling with, but also who has training and background and evidence based interventions.

You can't go to someone who says they treat trauma, but they don't do one of the interventions we've talked about.

That's critical, right?

It is critical that you're getting the right treatment.

But with the right treatment, man, you can get your life back.

And that's what today's all about.

So thank you.

You're welcome.

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And there's one thing that I need from you.

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