By Imperial County Behavioral Health Services
There’s a “kinder, gentler therapy” at work for those seeking treatment for post-traumatic stress disorder at Imperial County Behavioral Health Services.
That’s how Dr. Patricia Resick, Professor of Psychiatry and Behavioral Sciences at Duke University Medical Center, described Cognitive Processing Therapy, the evidence-based program she developed with Drs. Candice Monson and Kathleen Chard, and what she has been teaching the county’s Behavioral Health Services clinicians and practitioners since 2008.
The National Institute of Mental Health defines PTSD as “a disorder that develops in some people who have seen or lived through a shocking, scary, or dangerous event. … Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD.”
Over the decades, post-traumatic stress disorder has been what many think of as primarily affecting military servicemen and women returning home from war, unable to shake memories of their experiences. But as more is discovered about trauma and its effects on the mind, it is indisputable that the reach of PTSD extends deep into the population at large.
“PTSD seems to be a growth industry,” Resick said, explaining that there is no shortage of patients, even as people learn to deal with the disorder. National data back up her statement.
Statistics on the Veterans Administration’s PTSD website reflect that about 7 or 8 out of every 100 people (or 7-8 percent of the general population) will have PTSD at some point in their lives. About 8 million adults have PTSD during a given year, and about 10 of every 100 (or 10 percent) of women develop PTSD sometime in their lives compared with about 4 of every 100 (or 4 percent) of men.
In Imperial County, about 40 percent of people seeking treatment from Behavioral Health Services have PTSD, said Behavioral Health manager Scott Dudley, who co-hosts the Behavioral Health Services Wellness Radio program. He said PTSD often is accompanied by anxiety, depression, or psychotic disorders, which are addressed through therapy, medication, or a combination of the two.
WHAT DOES PTSD LOOK LIKE?
In order to be diagnosed with PTSD, one must meet “stressor criterion,” which may come into play through one or more of the following: death or serious illness of a loved one, war or combat, car accidents and plane crashes, natural disasters, and violent crimes.
For its sufferers, “The biggest symptom, the most difficult part of PTSD, is avoidance,” said Mary Esquer, who manages the Behavioral Health Services Anxiety and Depression Clinic in El Centro. “That avoidance is attributed to however that person connects the incident to themselves. If it was a rape, it could be any guy within that age range or appearance. If they were molested by a grandfather, it could be anyone who has white hair. That could be their trigger.”
Hypervigilance and increased awareness of one’s own circumstances then can become obsessions.
“Control is a big thing for people with PTSD,” said Resick, the psychiatrist behind Cognitive Processing Therapy used in Imperial County and around the world. “They have to control their environment.”
Cognitive Processing Therapy is a more pragmatic way of dealing with PTSD that helps patients address the trauma and learn to alter how they think and react to it, with a more permanent resolution than they might obtain through other types of treatment.
“CPT teaches new skills, to become their own therapist,” Resick told Behavioral Health Services staff. Once they complete therapy, she said, “People don’t relapse. Once you’ve treated them, you’ve treated them.”
CPT is defined in training coursework as a structured, short-term treatment that helps PTSD patients understand their symptoms, explore how trauma has affected their lives and learn about connections between trauma-related thoughts, feelings, and behaviors.
“This is not standard therapy where you can just sit back and talk,” Resick told Behaviorial Health Services staff during training. “If you learn better socratic questioning, you’ll get better results,” helping adult patients identify and get past the “stuck points” that hinder recovery.
“A stuck point is pretty much a failure to recover from a traumatic event,” said Esquer of Behavioral Health’s Anxiety and Depression Clinic in El Centro. “(Trauma) can happen anywhere in the continuum of life, and there are multiple traumas that people experience. They might not get traumatized by the first experience, but they might get traumatized by a second or third.”
Many people get “stuck” in the recovery process, Esquer said, because “Something in us facilitates recovery, and something in us hinders recovery. What can hinder recovery are intrusive images and sensations that come as we remember and try to avoid.”
In addressing the stuck points, Resick said a practical approach involves the patient in seeking the solution. “You’re telling them, we’re going to look at your PTSD and find out where you are stuck and how to get you unstuck. We’ll think about it together.”
Cognitive theory takes the approach that once a trauma is over it becomes a memory, important information that has to be integrated. People have three possibilities in dealing with that information. The first is that they assimilate and the trauma reinforces their perception of themselves, either for positive or negative, resulting in becoming “stuck.” The opposite scenario is that they over-accommodate and interpret everything in light of the new information, often feeling that the world is unsafe and they are alone, again becoming “stuck.” The third response is one therapists look for: accommodation, or changing their view of the world/themselves to incorporate the new information. This is a more balanced separation of beliefs from the trauma.
Resick said many people with PTSD don’t understand that bad things like rape, murder, accidents, molestation and the horrors of war, will happen to good people, and negative viewpoints of oneself result.
BRAINS AFFECTED EARLIER
Many experts believe that the foundation for PTSD is formed in one’s youth, Resick included.
“The prefrontal cortex comes fully online at age 24, which is why PTSD happens to younger people,” Resick said. The prefrontal cortex is the part of the brain mainly responsible for developing and regulating cognitive, emotional and behavioral functions.
“Who drives fast? Who makes risky decisions that can lead to trauma? Who is on front lines?,” Resick asked. “Older people have developed a method of handling tragedy.”
When the amygdala, the area in the brain that activates under stress, because aware of a threat, the body is designed to face that situation (fight) or escape (flight), explained Lillian Vera, a licensed clinician social worker with Behavioral Health Services. Once activated, the amygdala releases hormones to help the body respond to stress by boosting blood sugar, increasing oxygen, and pushing more blood to the brain and muscles to maintain energy and increase alertness, she said.
“This area in our brain is typically in the ‘off’ position, but in people that have experienced trauma, it might turn to the ‘on’ position and remain that way,” Vera said. “This leads to a person experiencing anxiety, reduced concentration, frustration, sleep problems, agitation, depression, mood swings, all of which can lead to difficulties in completing everyday tasks.”
All of that extra energy comes at a high cost to body and brain.
“It might lead to a weak immune system, difficulties recovering from illnesses and infections, slowing down the metabolism and preventing the body from getting nutrients it needs,” Vera said. Anxiety, high blood pressure, depression, and autoimmune diseases all have a greater chance of developing, experts say.
Help breaking that pattern to become healthier mentally, and in the long run physically, can be found through programs like those at the county’s Behavioral Health Services. But others far from the public sector are benefitting from CPT. The therapy is being used in prisons across the country, which “are full of people with PTSD,” Residk said. The disorder’s symptoms can result in poor choices, among them acts that land those affected behind bars. Among those poor choices are substance, emotional and physical abuses.
“Emotional abuse sets the stage for anything that follows,” Resick said. “You never find physical abuse without emotional abuse. People often get into an abusive relationship because that’s familiar to them.”
CPT can help break that pattern by helping those with PTSD learn to manage their symptoms.
“CPT isn’t the cure for just anything, but it is a PTSD treatment,” Resick said.
Four Types of PTSD Symptoms
(From the National Center for PTSD, http://www.ptsd.va.gov)
Reliving the event (also called re-experiencing symptoms)
Avoiding situations that remind you of the event
Negative changes in beliefs and feelings
Feeling keyed up (also called hyperarousal)
Diagnostic criteria, Diagnostic and Statistical Manual of Mental Disorders, revision 5
Exposure results from one or more of the following in which the individual
Directly experiences the traumatic event
Witnesses the traumatic event in person
Learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental)
Experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).
Treatment Pays Off For Veteran With PTSD
In the decades since “Frank” was wounded in the Gulf War, the 20-year U.S. Army veteran found himself homeless, living on the streets of Southern California communities, suffering from what would be diagnosed as Post-Traumatic Stress Disorder.
“Frank,” whose name has been changed to protect his identity, was rescued by an Imperial County law enforcement officer who recognized that the veteran was in crisis, a man who posed a threat to himself but not to those around him. Frank was taken to Imperial County Behavioral Health Services, where he was diagnosed and put on a treatment path that includes Cognitive Processing Therapy, an evidence-based therapy model that has proven successful in treating adults with PTSD.
More than a year later, Frank continues to be treated by Behavioral Health Services staff. His case worker, Alejandra Esquivel, checks on him regularly, takes him to doctors’ appointments, makes sure he attends weekly meetings with Behavioral Health Services staff, and has helped him navigate the daily activities many of us take for granted, like grocery shopping.
Through programs in place at Behavioral Health Services, the Adult Anxiety and Depression team working with Frank connected him with the federal, state and county resources that helped him find a home, his “safe place,” and additional funds with which to pay his monthly bills. Frank even has a service dog he calls his “best friend” that helps ease his anxiety.
Frank says there are many veterans like him, and he hopes by sharing his story that they will come out of the shadows and seek help.
“There’s a lot of vets out there that think, ‘they don’t understand,’” he said of the mental health community. “But they do. They can help. I ran the streets for years and years and met a lot of vets, talked to a lot of vets. When vets talk, they talk straight. They don’t trust too many people to put them back together.”
Those who have long worked with veterans agree.
“A lot of veterans are suffering and not seeking that help out,” said Rafael Monroy, who counsels veterans at U.S. Department of Veterans Affairs clinics in Yuma and El Centro. Monroy, a former case worker at Imperial County Behavioral Health Services in El Centro, is himself a veteran who served in the infantry and was discharged in 2006.
Monroy landed on his feet, returning to school and eventually earning the degrees that allow him to help fellow veterans, many of them suffering with PTSD and other disorders.
“You try to make their life better — instill the trust, make sure they’re safe, have a place to live, food. Basic needs,” Monroy said. “Once they have basic needs you can push more toward therapy.”
About 11 to 20 out of every 100 veterans who served in the nation’s most recent wars in Iraq and Afghanistan – Operations Iraqi Freedom and Enduring Freedom — will have Post-Traumatic Stress Disorder in a given year, according to U.S. Department of Veterans Affairs data. About 12 of every 100 veterans of the Gulf War have PTSD in a given year, and about 30 of every 100 Vietnam veterans have had PTSD in their lifetime.
Veterans who go undiagnosed and/or untreated for years often develop disorders on top of PTSD, and eventually withdraw from the world around them. Many seek solace in alcohol or other forms of substance abuse.
Withdrawal, or isolationism, is a common thread among those with PTSD, said Monroy.
“You stop talking to friends, stop talking to family. That’s where people can spiral down pretty quickly, because you’re quitting all your support networks,” Monroy said.
Those behaviors increase the risk of homelessness.
According to the National Alliance to End Homelessness, traumatic brain injuries suffered during combat and post-traumatic stress disorder “have been found to be among the most substantial risk factors for homelessness.” Nearly 50,000 veterans were identified as homeless in early 2014, according to Alliance data.
Frank is one of the lucky ones. Through the county, he found treatment for his alcohol abuse along with the PTSD. He still struggles with flashbacks and nightmares, and battles intense anxiety and a wariness of unfamiliar faces. He prefers to be alone, but has developed trust in those helping him. Without their help, he said, he might not have survived.
Esquivel said Behavioral Health Services not only is helping Frank learn to cope through therapy, but its staff helped him get county assistance and increased VA benefits. The department’s case management team links clients to community and social services, makes sure they attend doctor’s appointments and are in compliance with their medications and monitors symptoms and behavior to help improve social function. The team monitors daily living activities, teaches techniques to improve socialization, provides rehabilitation skills, acts as coaches and advocates, reinforces techniques taught by clinicians, and does risk and crisis assessments.
Said Monroy, “Unfortunately there’s a lot of stigma about (seeking help). But anyone can have depression. Anyone can have anxiety. If you need the help, go ahead and get it.” He described Behavioral Health Services as “a one-stop shop. You can get a nurse, you can get a doctor, you can get a therapist, you can get a case worker, you can get a lot of stuff in that office. You can get all the help you need in that place.”
Those who work with Frank at Behavioral Health Services see him as a success story among veterans being treated for PTSD.
“Frank was our most difficult case as far as PTSD in veterans,” said Mary Esquer, manager of Behavioral Health Services’ Adult Anxiety and Depression Clinics. “When he came in he was at rock bottom, and now he is thinking about his future.”
“I went from somebody who didn’t care to, ‘What am I going to do today?’,” Frank said. “For a soldier like me, (this program), it’s good. I’m blessed.”