Treating Trauma in a “Zoom” World: Is it even possible?

You might wonder if it is possible to treat post-traumatic stress disorder (PTSD) during a COVID-19 pandemic crisis, but this is the situation that therapists and clients find themselves. Can we find a way to maintain effective treatment through the use of modern technology? Is it possible to treat trauma with this “new world” approach to mental health?

Since the beginning of this year (2020), countries worldwide have worked to protect vulnerable populations from the virus COVID-19. The primary strategies used to prevent the spread of the virus is social distancing and self-imposed quarantine. While this has been effective in reducing the pandemic’s physical effects, it hasn’t protected us from the psychological effects of this unprecedented life-situation. We see an increase in fear, anger, anxiety, panic, helplessness, and burnout in both children and adults. As a therapist working remotely with people dealing with stress and trauma, I have seen several extreme reactions of hallucinations and delusions due to the isolation and continual digestion of negative news media. 

A Healthline.com survey of what COVID-19 is doing to our mental health gives a somber picture: increased worry and insecurity over finances, higher than normal depression and anxiety, prevalent feelings of sadness, and being “on edge,” and an alarming rise in suicides. In America, Federal dollars are being released to increase mental health services nationwide to stem this rising tide of trauma without fully knowing the long-term effects of trauma. 

Therapists, just like the general population, use social distancing and remote work to keep themselves, their families, and their clients safe. Therapists are “front-line responders” and considered “essential workers,” but not all therapists choose to be exposed to 30-40 people a week who might have the COVID virus. Many of them, like myself, have family members who have compromised immune systems and considered to be at-risk. Working from an office and seeing individuals, face-to-face is not an option. Therefore, therapists and clients have to seek alternatives that can be equally beneficial to both. 

The European Journal of Psychotraumatology studied the Telehealth models for post-traumatic stress disorder using cognitive therapy and found that clients rated it as very successful in managing their symptoms. High patient satisfaction ratings were given for both video conferencing and phone call sessions. In the later technology, the only nonverbal communication was the tone of voice, and yet it still benefited clients. 

The journal defines Post-traumatic stress disorder by “a sense of serious current threat, which has two sources: the nature of the trauma memory and excessive negative appraisals.” Traumatized individuals frequently have intrusive, negative thoughts about traumatic experiences and continue to see the world with a negative lens. They have a feeling of hopelessness about their future and easily triggered by daily events. 

Professional organizations are rising to the challenge and providing education and support to remote mental health workers on the unique delivery of mental health through technology. Guidelines have been created by the American Psychological Society, International Society of Traumatic Stress Studies, and the National Institute of Health and Clinical Excellence, specifically targeting PTSD. Governing boards for various mental health professionals are also outlining specific legal and ethical requirements for safe, trustworthy online therapy. 

According to the Psychotraumatology journal article, Telehealth’s use led to “improvements in PTSD symptoms, disability, depression, anxiety, and quality of life, and over 70% of patients recovered from PTSD (meaning they no longer met diagnostic criteria). The Journal of Family Process has reported several articles on the effectiveness of Telehealth with children, adults, couples, and families.

Therapists, offline and online, can provide education and support to (1) reduce negative reactivity in thoughts and emotions, (2) build more effective coping skills, and (3) deepen the quality of life and relationships.

These three areas are healing strategies outlined in my trauma-informed training and therapy. 

The foundation for PTSD work, in face-to-face or video conferencing, is to establish a sense of safety from which to utilize these healing strategies. The client has to trust the therapist, believing he can offer some hope, create an atmosphere of security, and witness the traumatic hurt for PTSD individuals. Empathy isn’t confined to the physical space of the therapist’s office. It can exist in the relational space online as well. Facial expressions on video, tone of voice, empathic responses, and supportive comments assist the connection despite distances.

Finding a private place to have a conversation is one real-world challenge of online work. Privacy can be increased by changing locations (some of my clients go inside cars, relocating to other rooms in the house, or going outside), using headphones, and letting family members know that they can’t be disturbed hour or so. Additionally, therapists can also learn about resources in the client’s living area if referrals are needed. Homework assignments can also be used between sessions and discussed online for adolescents and adults. Parents can participate online with young children, and family members can “zoom” in from different locations at an agreed-upon time. And lastly, follow up with secure emails and text messaging can further increase the outcome of this digital therapeutic medium for PTSD. 

If you are looking for a trauma therapist or someone to help you or a family member with anxiety, contact Ron Huxley today at RonHuxley.com

Be sure to take advantage of our free online resources for families during the COVID-19 Pandemic at FamilyHealer.tv

References: https://www.healthline.com/health-news/what-covid-19-is-doing-to-our-mental-health

https://www.tandfonline.com/doi/full/10.1080/20008198.2020.1785818

https://www.apa.org/practice/guidelines/telepsychology

https://www.ptsd.va.gov/professional/treat/txessentials/telemental_health.asp

17 Hugs A Day

My wife and I have a joke that we tell each other and family members: It takes a minimum of 17 hugs a day to feel normal. I will confess that there is no scientific research that supports 17 hugs per day therapy…at least not yet. Nevertheless, we have come to recognize that need for touch and have adopted the idea that hugs, at least 17 is what gets us through the daily life hassles. At a recent conference on Attachment Theory, where there was some real scientific data, a presenter on PTSD- Post Traumatic Stress Disorder that stated that data suggests that the little stressors of everyday living can add up to the same effects of someone who has undergone a single, major life trauma, like a robbery or death of a loved one or car accident.
We let these little incidents of life go by without any real concern. Perhaps we feel embarrassed to admit how much a poor marriage or teenager defiance or even workplace stress really does affect us. Can parents acts as prevention specialists for our children. As adults, we need 17 hugs just to maintain normal living? Our children need them to counter the cumulative effects of stress on their lives to avoid PTCS – Post Traumatic Childhood Stress.
If you don’t believe there is a such a thing, just observe children interacting on a play ground. There are some mean things thrown back and forth on the jungle gym, let me tell you! Add to that some homework pressures and the constant media bombardment of negative words and images and what child wouldn’t feel slightly traumatized? As parents, the least we can do is give some touch therapy with a few hugs a day.
John Bowlby, the great attachment theorist, stated that attachment is essential to normal development. Guardians are supposed to be our safe haven from life. Home should be a place of refuge from the constant stress of school and work. Granted, there are chores and homework to be done but how can you carve our 30 minutes a day for some connection. Parents are quick to use Time-Out, how about some Time-In? It might be good for mom and dad too. Starting today, give a few more hugs than usual. It is OK to start slow and work your way up. And yes, teenagers love them too. You just have to be a little more crafty in your approach.  

How Trauma Affects A Child’s Brain

Ron Huxley Trains: I am conducting a lot of trainings around the country on “The heArt and Science of Trauma” for parents and professionals, so this video is interesting and validates the information I have researched and teach in my presentations. If you would like a free consult on bringing this training to your organization or system of care, email me at rehuxley@gmail.com

Exposure to Intimate Partner Violence, Peer Relations, and Risk for Internalizing Behaviors

Exposure to Intimate Partner Violence, Peer Relations, and Risk for Internalizing Behaviors

A Prospective Longitudinal Study

  1. Kathleen Camacho1
  2. Miriam K. Ehrensaft1
  3. Patricia Cohen2

  1. 1John Jay College of Criminal Justice, New York

  2. 2Columbia University, New York State Psychiatric Institute, New York
  1. Miriam K. Ehrensaft, John Jay College of Criminal Justice, 445 West 59th street, New York, NY 10019 Email: mehrensaft@jjay.cuny.edu

Abstract

The present study examines the quality of peer relations as a mediator between exposure to IPV (intimate partner violence) and internalizing behaviors in a sample of 129 preadolescents and adolescents (ages 10-18), who were interviewed via telephone as part of a multigenerational, prospective, longitudinal study. Relational victimization is also examined as a moderator of IPV exposure on internalizing behaviors. Results demonstrate a significant association of exposure to severe IPV and internalizing behaviors. Relational victimization is found to moderate the effects of exposure to severe IPV on internalizing behaviors. The present findings suggest that the effects of exposure to IPV had a particularly important effect on the risk for internalizing problems if the adolescent also experienced relational victimization. Conversely, the receipt of prosocial behaviors buffer against the effects of IPV exposure on internalizing symptoms in teen girls.

Ron Huxley Relates: This study simply backs up our belief that witnessing domestic violence has a negative effect on children. This article focuses specifically on teens and how one’s peer group can help to buffer those negative effects. Apparently, teen girls have reduced effects when they have a strong peer network. Perhaps all that texting is good for them? OK, maybe that goes to far but it does support another belief that group therapy, formally or informally, can help our adolescents who have been victimized in this way.

Child Abuse May Alter Structure of the Brain, Research Shows – Businessweek

By Nicole Ostrow

Dec. 5 (Bloomberg) – Teenagers who were abused as young children show changes in their brains that put them at risk for behavioral problems in adulthood, according to research from Yale University.

Brain scans of adolescents who suffered physical abuse and neglect showed differences in the part that controls executive function – mental processes such as planning, organizing and focusing on details – according to a study in the Archives of Pediatric and Adolescent Medicine. Changes were also seen in brain areas that regulate emotions and impulses, the study said.

About 3.7 million U.S. children are assessed for child abuse or neglect each year, but the number may be higher as many cases don’t come to the attention of professionals, the authors said. The research, which evaluated teenagers who hadn’t been diagnosed with a psychiatric disorder, suggests abuse or neglect victims be monitored to reduce the risk of disorders like depression and addiction, researchers said.

“What these findings show is that experiences that people have early in life can really subsequently and fundamentally alter the way their brain develops,” said Philip Fisher, who wrote an accompanying editorial in the journal. “These kids, in spite of the fact that they didn’t have actual disorders, have the potential to be very vulnerable for problems over the course of their development.”

Human brains continue to develop through early adulthood, particularly the area that regulates emotions and executive function, said Fisher, a professor of psychiatry at the University of Oregon and a senior scientist at the Oregon Social Learning Center in Eugene, in a Dec. 2 telephone interview.

Gender Differences

The study included 42 kids ages 12 to 17 who didn’t have a psychiatric diagnosis. The researchers used questionnaires to determine if the children suffered from physical abuse, physical neglect, emotional abuse, emotional neglect and sexual abuse. They then took images of their brains using MRI.

Scans showed that girls were more likely to have differences in brain areas related to emotional processing, making them more vulnerable to mood disorders like depression, while boys had changes to areas for impulse control, which could make them more vulnerable to drug and alcohol addictions, said study author Hilary Blumberg, an associate professor of psychiatry and diagnostic radiology in the Child Study Center at Yale School of Medicine in New Haven, Connecticut.

Neglected Children

Brain alterations occurred in both adolescents who suffered abuse as well as neglect, the research found. The study didn’t show distinct patterns in the brains of children who were sexually abused, although Blumberg said that may be because the number of children who were sexually abused was small.

“It was very important to see the findings with regard to neglect,” Blumberg said in a Dec. 2 interview. “That was an area that had been little studied.”

Researchers are continuing to follow these teens to see if they develop behavior problems like depression or substance abuse and to understand why some may develop issues while others don’t, she said.

–Editors: Angela Zimm, Bruce Rule

To contact the reporter on this story: Nicole Ostrow in New York at nostrow1@bloomberg.net

To contact the editor responsible for this story: Reg Gale at rgale5@bloomberg.net

Ron Huxley’s Reaction: The information in this blog post is not new to anyone working with abused and neglected children. What is interesting is that it is posted on a very well respected business site. This tells me that the mainstream is beginning to get a clue about a very serious problem that might result in funding to help. To be really effective, we have to attack this issue “before” it gets to a crisis level and cost us more in the form of juvenile justice and mental health programs. Let’s work with the families to prevent the abuse and neglect from happening in the first place!

Firesetting: Why kids do it and how parents can manage it

For parents, the dangers of fire are so apparent that the sight of a child anywhere near a flame is enough to send them scrambling. And fortunately, most kids are afraid of fire and understand that it can hurt them and others.

But it’s not unusual for kids to be curious about fire, too. After all, we enjoy campfires and singing over birthday candles. That’s why it’s so important to educate kids about the dangers of fire and to keep them away from matches, lighters, and other fire-starting tools.

Even with the best efforts from parents, kids might play with fire. Most of the time this can be handled by explaining the dangers and setting clear ground rules and consequences for not following them.

But sometimes kids seem to be especially preoccupied with fire and repeatedly attempt to set things on fire, which can be a sign of emotional and behavioral issues that require professional help.

Why Kids Set Fires

Young children who set fires usually do so out of curiosity or accidentally while playing with fire, matches, or lighters, and don’t know how dangerous fire can be. During the preschool years, fire is just another part of the world they’re exploring. Unfortunately, these fires tend to be the most deadly because kids in that age group don’t know how to respond to a fire, and may set it in a small, enclosed space, such as a closet.

As kids get a little older, they might be fascinated with fire. It’s fairly common for them to do things like light paper with matches, set things on fire using a magnifying glass, or play with candles or other things that have a flame. That’s usually not a cause for concern.

But if a school-age child deliberately sets fires, even after being reprimanded or punished, a parent needs to talk to the child and consider getting professional help. That’s especially true if the child is setting fires to larger objects or in areas where the flames can easily spread and cause injury and damage.

Talk with your doctor or consult a mental health professional if your child exhibits behaviors such as:

  • adding more fuel to fires in the fireplace, grill, or campfires, even when told not to
  • pocketing matches or hiding fire-starting materials
  • lighting candles, fireworks, and other things, despite being told not to

Kids might set fires for any number of reasons. They may be angry or looking for attention. They may be struggling with stressful problems at home, at school, or with friends. Some set fires as a cry for help because they’re being neglected at home or even abused. Even if they know how dangerous fire can be, they might have other problems that involve difficulty with impulse control.

Whatever the reason for firesetting, parents need to get to the root of the behavior and address underlying problems. It’s important to consider seeking professional help as soon as possible to prevent serious damage or injury.

Ron Huxley’s Response: I wanted to find an article on firesetting because it is a problem that we (parents and professionals) don’t talk much about. This blog post gives a good introduction into firesetting by children. It follows my “80/20” rule about misbehavior: 80% of the children do it for curiosity and attention-getting. 20% do it for more serious, underlying causes. It is this later group that parents need to take action on immediately by consulting with a professional. How have you dealt with this frightening behavior?

What 9/11 has taught us about trauma

Scientific American has a useful piece on how the immediate treatment of psychological trauma has changed since 9/11. The issue is interesting because recent progress has turned lots of psychological concepts on their head to the point where many still can’t grasp the concepts.

The article notes that at the time of the Twin Towers disaster, the standard form of treatment was Critical Incident Stress Debriefing – also known as CISD or just ‘debriefing’ – a technique where psychologists would ask survivors, usually in groups, to describe what happened and ‘process’ all the associated emotions by talking about them.

This technique is now not recommended because we know it is at best useless and probably harmful – owing to the fact that it seems to increase trauma in the long-term.

Instead, we use an approach called psychological first aid, which, instead of encouraging people to talk about all their emotions, really just focuses on making sure people feel secure and connected.

Although the article implies that 9/11 was a major turning point for our knowledge of immediate post-trauma treatment, the story is actually far more complex.

Studies had been accumulating throughout the 90s showing that ‘debriefing’ caused harm in some, although it wasn’t until around the turn of the century that two meta-analyses sealed the deal.

Unfortunately, the practice of ‘debriefing’ by aid agencies and emergency psychologists was very hard to change for a number of interesting reasons.

A lot of aid agencies don’t deal directly with the scientific literature. Sometimes, they just don’t have the expertise but often it’s because they simply have no access to it – as most of it is locked behind paywalls.

However, probably most important was that even the possibility of ‘debriefing’ having the potential to do damage was very counter-intuitive.

The treatment was based on the then-accepted foundations of psychological theory that said that emotions always need to be expressed and can do damage if not ‘processed’.

On top of this, for the first time, many clinicians had to deal with the concept that a treatment could do damage even though the patients said it was helpful and were actually and genuinely getting better.

This is so difficult to grasp that many still continue with the old and potentially damaging practices, so here’s a quick run down of why this makes sense.

The theoretical part is a hang-over from Freudian psychology. Freud believed that neuronal energy was directly related to ‘mental energy’ and so psychology could be understood in thermodynamic terms.

Particularly important in this approach is the first law of thermodynamics that says that energy cannot be created or destroyed just turned into another form. Hence Freud’s idea that emotions need to be ‘expressed’ or ‘processed’ to transform them from a pathological form to something less harmful.

We now know this isn’t a particularly reliable guide to human psychology but it still remains hugely popular so it seemed natural that after trauma, people would need to ‘release’ their ‘pent up emotions’ by talking about them lest the ‘internal pressure’ led to damage further down the line.

And from the therapists’ point of view, the patients said the intervention was helpful and were genuinely getting better, so how could it be doing harm?

In reality, the psychologists would meet with heavily traumatised people, ‘debrief’ them, and in the following weeks and months, the survivors would improve.

But this will happen if you do absolutely nothing. Directly after a disaster or similarly horrible event people will perhaps be the most traumatised they will ever be in their life, and so will naturally move towards a less intense state.

Statistically this is known as regression to the mean and it will occur even if natural recovery is slowed by a damaging treatment that extends the risk period, which is exactly what happens with ‘debriefing’.

So while the treatment was actually impeding natural recovery you would only be able to see the effect if you compare two groups. From the perspective of the psychologists who only saw the post-trauma survivors it can look as if the treatment is ‘working’ when improvement, in reality, was being interfered with.

This effect was compounded by the fact that debriefing was single session. The psychologists didn’t even get to see the evolution of the patients afterwards to help compare with other cases from their own experience.

On top of all this, after the ‘debriefing’ sessions, patients actually reported the sessions were useful even when long-term damage was confirmed, because, to put it bluntly, patients are no better than seeing the future than professionals.

In one study, 80% of patients said the intervention was “useful” despite having more symptoms of mental illness in the long-term compared to disaster victims who had no treatment. In another, more than half said ‘debriefing’ was “definitely useful” despite having twice the rate of postraumatic stress disorder (PTSD) after a year.

Debriefing involves lots of psychological ‘techniques’, so the psychologists felt they were using their best tools, while the lack of outside perspective meant it was easy to mistake instant feedback and regression to the mean for actual benefit.

It’s worth saying that the same techniques that do damage directly after trauma are the single best psychological treatment when a powerful experience leads to chronic mental health problems. Revisiting and ‘working through’ the traumatic memories is an essential part of the treatment when PTSD has developed.

So it seemed to make sense to apply similar ideas to those in the acute stage of trauma, but probably because the chance of developing PTSD is related to the duration of arousal at the time of the event, ‘going over’ the events shortly after they’ve passed probably extends the emotional impact and the long-term risks.

But while the comparative studies should have put an end to the practice, it wasn’t until the World Health Organisation specifically recommended that ‘debriefing’ not be used in response to the 2004 tsunami [pdf] that many agencies actually changed how they went about managing disaster victims.

As well as turning disaster psychology on its head, this experience has dispelled the stereotype that ‘everyone needs to talk’ after difficult events and, in response, the new approach of psychological first aid was created.

Psychological first aid is actually remarkable for the fact that it contains so little psychology, as you can see from the just released psychological first aid manual from the World Health Organisation.

You don’t need to be a mental health professional to use the techniques and they largely consist of looking after the practical needs of the person plus working toward making them feel safe and comfortable.

No processing of emotions, no ‘disaster narratives’, no fancy psychology – really just being practical, gentle and kind.

We don’t actually know if psychological first aid makes people less likely to experience trauma, as it hasn’t been directly tested, although it is based on the best available evidence to avoid harm and stabilise extreme stress.

So while 9/11 certainly focussed people’s minds on psychological trauma and its treatment (especially in the USA which is a world leader in the field) it was really just another bitter waymarker in a series of world tragedies that has shaped disaster response psychology.

So unusually for a psychologist, I’ll be hoping we’ll have the chance to do less research in this particular area and have a more peaceful coming decade.
 

Link to SciAm piece on psychology and the aftermath of 9/11.

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This isn’t a typical piece for a parenting blog but seeing as how I work with so many traumatized children and since today is 9/11 it seemed appropriate to share a couple thoughts.

One of the first things I teach my clinical interns is that you have to “stabilize” before you can do “interventions.” As therapists and parents we want to help a child talk about their traumas and get it all out. As the article explains above, this is an out dated and incorrect hypothesis about how to manage trauma. What children need FIRST is to know that they are safe and connected to others. This is the first law of attachment if you will and the very thing that so many traumatized children lack. Think about it: trauma destabilizes your sense of safety, so what would be the best intervention? Recreating safety.

It is a common problem for new therapists to want to talk it out. I get social workers and parents pressing me to do this all the time. The fact is that it is the worst thing for the child at first. Before working out issues, let’s create safety and stability at home and school. Build more support system. Give more hugs. Stay longer in the room at night and read that extra book or two. Be more tolerant of the meltdowns and resistance to changes in routine. Follow a routine if you don’t have one. Give back rubs and an extra scoop of ice cream.

What do you do to create safety and stability after a child experiences something traumatic?

17 Hugs A Day

My wife and I have a joke that we tell each other and family members: It takes a minimum of 17 hugs a day to feel normal. I will confess that there is no scientific research that supports 17 hugs per day therapy…at least not yet. Nevertheless, we have come to recognize that need for touch and have adopted the idea that hugs, at least 17 is what gets us through the daily life hassles.

At a recent conference on Attachment Theory, where there was some real scientific data, a presenter on Post Traumatic Stress Disorder stated that data suggests that the little stressors of everyday living can add up to the same effects of someone who has undergone a single, major life trauma, like a robbery or death of a loved one or car accident. We let these little incidents of life go by without any real concern. Perhaps we feel embarrassed to admit how much a poor marriage or teenager defiance or even workplace stress really does affect us.

Can parents acts as prevention specialists for our children. As adults, we need 17 hugs just to maintain normal living. Our children need them to counter the cumulative effects of stress on their lives to avoid PTCS – Post Traumatic Childhood Stress. If you don’t believe there is a such a thing, just observe children interacting on a play ground. There are some mean things thrown back and forth on the jungle gym, let me tell you! Add to that some homework pressures and the constant media bombardment of negative words and images and what child wouldn’t feel slightly traumatized? As parents, the least we can do is give some touch therapy with a few hugs a day.

John Bowlby, the great attachment theorist, stated that attachment is essential to normal development (see my blog post on this here). Guardians are supposed to be our safe haven from life. Home should be a place of refuge from the constant stress of school and work. Granted, there are chores and homework to be done but how can you carve our 30 minutes a day for some connection. Parents are quick to use Time-Out, how about some Time-In? It might be good for mom and dad too.

Starting today, give a few more hugs than usual. It is OK to start slow and work your way up. And yes, teenagers love them too. You just have to be a little more crafty in your approach.