TARGETing PTSD

Post-traumatic stress disorder is often associated with military combat and experiencing a traumatic situation, such as the Sandy Hook school shooting. A few weeks ahead of the 10-year anniversary of that tragedy, we discuss PTSD with UConn Health clinical psychologists Julian Ford and Rocio Chang. They explain what PTSD is and isn’t, differentiate between PTSD and the somewhat newly diagnosed form known as “complex PTSD,” what we’ve learned in the 10 years since Sandy Hook, and how to help those affected by PTSD — including a treatment approach known as TARGET, which our guests helped develop.

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(Dr. Julian Ford, Dr. Rocio Chang, Carolyn Pennington, Chris DeFrancesco, November 2022)

Transcript

Chris: What triggers someone to mentally relive and have a reaction to something well after it happens? And how and why does that affect us? Today on the Pulse, we discuss PTSD and the relatively new complex PTSD.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and hopefully leave you with some health information you’ll find useful.

With Carolyn Pennington, I’m Chris DeFrancesco. Experiencing an unthinkable tragedy or dealing with the mental scars of military combat are just two examples of experiences that can lay the foundation for post-traumatic stress disorder.

Carolyn: And it’s a subject that often comes up around Veteran’s Day and when looking back on historic events like 9/11, and coming up soon with the 10-year anniversary of the Sandy Hook school shooting in Newtown. So we’ve brought in two experts to talk about it with us: Dr. Julian Ford, a clinical psychologist at UConn Health who directs the Center for the Treatment of Developmental Trauma disorders, and Dr. Rocio Chang, also a UConn Health clinical psychologist, whose expertise includes child and adolescent psychiatry. Thank you both for joining us.

Dr. Chang: Thank you.

Dr. Ford: Thank you. Carolyn.

Carolyn: It seems PTSD has become a term a lot of us use to describe how we feel when something brings up a bad memory. But is that an accurate diagnosis? Let’s start with you, Dr. Ford. Is that a, a good way to describe PTSD?

Dr. Ford: Actually, no, carolyn, what we are thinking about when we are feeling stressed or distressed, those are stress reactions and that can happen to anyone any time. Post-traumatic stress disorder, or PTSD, is a much more serious condition. It’s a reaction to life-threatening experiences, fundamentally shocking, terrifying, or horrifying experiences, so not the run-of-the-mill experiences that we all have every day, and the stresses that we all deal with in our lives. PTSD really involves, as Chris said earlier, memories that come back, unwanted, that just seem to capture you in a way that you can’t escape. And along with those memories, then there’s a natural tendency to try to do anything possible to avoid the memories, but unfortunately, the more you try to avoid thinking about something, the more that you end up thinking about it. So avoidance actually then brings back the memories even more strongly. And as a result, people who are dealing with PTSD feel a sense of hypervigilance, like they’re never safe, can never let down their guard, and that makes it really difficult to sleep, to relax, to enjoy other people, to do your work. So that’s why PTSD is a disorder. It’s not just a stress reaction. It is a fundamental difficulty because of terrible things that have happened, and we know why that happens. And we’ll talk more about that.

Chris: I think that is an important distinction, Dr. Ford, thank you for clarifying that. Now, one of the reasons I wanted to bring you in was, in dealing with you over the course of our jobs, the issue of complex PTSD came up, which is something I hadn’t heard of. Of course you have, but I guess that that’s been around for a while, but it’s become a little more accepted in recent years. So why don’t you talk just a little bit about kind of the distinction between PTSD and complex PTSD, kind of what’s that distinction?

Dr. Ford: Absolutely, Chris, and PTSD itself is quite complex. However, the International Classification of Diseases, which is a diagnostic system that’s accepted all over the world, a couple of years ago made a decision based on research and clinical evidence that there is a variation of PTSD that is even more complex. So in PTSD we have the unwanted memories, the avoidance and the hypervigilance. Complex. PTSD adds to that a fundamental difficulty with just managing one’s emotions, having emotions that are so intense or so shut down that the individual just doesn’t really know what to do with their emotions. And, as a result, they often feel very, very intensely troubled in their relationships. And that’s a second aspect of complex PTSD, a really fundamental difficulty in relating to other people because of a sense of not feeling safe. And finally, complex PTSD also involves a fundamental change in how we view ourselves, our sense of who we are as a person. And that can involve a sense of, “I’m a person who’s just a failure and who is completely damaged and can never be repaired.” So as you can see, complex PTSD really cuts to the heart. It’s a very deep and very difficult problem to deal with.

Carolyn: Do you start off with PTSD and then go to complex PTSD, or is it something that just depends on you and your psychological makeup?

Dr. Ford: It can go that way, Carolyn. But what we know with complex PTSD is that those difficulties are particularly related to traumatic events and experiences that happened earlier in childhood. So very often what happens is that, psychological trauma happens in the lives of children more often than we would like to think. More than two-thirds of all children have experienced some form of trauma.

Carolyn: Really?

Dr. Ford: When it occurs early in life, especially before the age of six or seven or so, that can cause a fundamental change in how the child’s developing, because kids become essentially survival experts. And when they do that, then they’re not able to really pay attention to the the kinds of ordinary opportunities and challenges because they’re so busy just trying to make sure that they’re safe, that they can’t really focus on how to manage their emotions or how to deal with relationships. And these are not kids who are in any way not smart. These are very smart kids, but they are using their intelligence to try to survive rather than developing in a way that we would want them to be able to develop in a healthy sense.

Chris: And let’s talk about the kids. Dr. Chang, you’re a child and adolescent psychologist. Let’s define what a childhood trauma is because not everybody was in Newtown for the school shooting, but it doesn’t have to rise to that level to be considered a trauma and have real long-term implications for your development, right?

Dr. Chang: So, yes, thank you, great question. Dr. Ford already mentioned that a traumatic experience is a life-or-death experience, right? So kids who feel very terrified or horrified for something that’s happened and that is actually impacting at some level their perception of their own safety. And it has different types, right? So we talk about sexual abuse as a traumatic experience. We talk about witnessing domestic violence as a traumatic experience, being in a motor vehicle accident, a serious one. So there are many different types of traumatic events that children experience, and it depends on their perception of what happened, the after effects, it might also depend on how adults organize themselves to support whatever experience a child lives through.

Chris: That must be a huge part of it. And when you see a child in adolescent patient, Dr. Chang, what is the role of the parent in that type of therapy? I mean, there’s probably level of confidentiality, but there’s probably some involving by the parent as well, I would imagine. Or does it depend on the patient?

Dr. Chang: Definitely, because they’re part of a system and, in a way, parents are our best allies for treatment to be successful. And it also depends on the developmental stage of the child. Obviously when they’re younger, we definitely count more on parents to help us through. Kids need many different things in terms of keeping the structure going at home, feeling safe at home and other contexts where they’re part of. But it’s essential the parents also are educated about how trauma impacts the lives of children and how trauma impacts the lives of families and communities at large.

Carolyn: I know you’ve kind of touched on this, but what are some of the other challenges of treating, especially a really young child, like less than six years old?

Dr. Chang: Obviously we’re talking about very young children and many times it depends on when the trauma happened. They might not have a verbal memory. They cannot express that with words. There are other ways that kids express their experiences, and it’s many times through play. Other times, sometimes if they become disregulated, they might express it with tantrums and things of that nature. So it all depends on the developmental stage of the child. But we do have an expert in a model here that can talk a little bit more about TARGET, and how TARGET has been supporting many children, adolescents, and adults and families.

Dr. Ford: So there are some excellent treatment models for children who’ve experienced trauma and are having difficulties with post-traumatic stress disorder or complex PTSD. One of them is called trauma-focused cognitive behavioral therapy. In that, the child or adolescent develops a story of what happened to them, a real-life story. And that can be enormously helpful for kids because it doesn’t retraumatize them. It helps them to face the trauma memory, to recognize what happened, to stop avoiding thinking about it, and then to feel supported by their parent. And it also helps their parents, or caregivers, to see that they don’t have to try to protect their child from what has happened in the past. They can help them and keep them safe now, but they don’t have to constantly be worried about the memories that their child is experiencing.

There are other treatments that do not involve going back and actually reliving or retelling the trauma story. And one of those is a model that I’ve developed with my colleagues, including Dr. Chang, and it’s called Trauma Affect Regulation Guide for Education and Therapy. It’s TARGET for short, and in that therapy, what we do is we help kids or adults to actually look at ways in which they are reacting in their current lives that are triggered by similarities or reminders of traumas. So instead of focusing on the memory, we focus on their current reactions, which are almost always based on memories. So we don’t talk as much about the memories, we talk about the current experiences, and we also explain how trauma really changes something in the brain. It doesn’t create brain damage, it doesn’t make the brain less efficient, it focuses the brain on survival. And we even show them, the kids and their parents, oor caregivers, we show them how there’s an alarm in the brain that gets set off by trauma. It also gets set off by stress. And when it’s just an ordinary stress, you feel that sense of “Uh-oh, I’d better watch out. Maybe I’d better pay attention. I’d better wake up.” If it’s a trauma, it’s much more a reaction of, “Oh my gosh, how am I gonna survive this?” And when that happens, then that alarm gets set off in the brain by trauma, it can remain stuck on. And so you have a kid or an adult who’s still living with that feeling in their body and their brain as if they’re right in the middle of the trauma, even though they know they’re not. Once kids and adults understand that, they realize, “Oh, then if we have a way to turn down that alarm and reset it,” so now it’s working the way it should, rather being stuck in the emergency trauma mode. Then that’s what we can do to actually recover from PTSD. And we show them some wonderful ways to use other parts of the brain. There’s a part of the brain that we call the thinking center, which is the prefrontal cortex, which actually, if you mobilize it in the right way, If you tune in to what’s really important in your life and what you believe in and who’s there to support you — and we help kids and and parents do that — that actually sends a message that resets the alarm in the brain.

So we have a way that — there’s no medical aspect to this except for the fact that by thinking differently and approaching the memories and the current reactions differently, it’s actually possible to create a fundamental shift in how the brain is functioning. And that then is a way to recover from PTSD.

Chris: Before we say goodbye, we have the 10 year anniversary of the Sandy Hook School shooting in Newtown. And I’d like to hear from both of you, what have we learned about PTSD over these last 10 years? Not only for the kids who witnessed their classmates or teachers attacked, their siblings, the first responders who arrived to deal with it, the rest of us who watched it on the news, how that impacted us — probably different levels of impact on people depending on their relation to what happened that day. But what have we learned in the last 10 years in terms of how to help people deal with these kinds of things?

Dr. Chang: Maybe we have confirmed what we already knew about how PTSD is a disorder that impacts us and it can have a long term impact, right? So I think that one of the aspects that we all know also from those terrible tragedies and the one at Sunday Hook is the value of belonging to communities, that are supportive communities that value individuals, where we definitely, we’re not gonna forget, but we are also are supporting people who are struggling and also keeping the hope that better things will come and that we are not alone in this. So I, I think that the sense of community for me is the one that makes sense to continue valuing it because it is super important in moments of tragedies.

Dr. Ford: So beautifully stated. And all I can add is that I think we’ve learned that those kinds of horrible traumas happen in major ways, like in Sandy Hook, for kids from all kinds of backgrounds. But they’re also happening every day for many children who are living in poverty, who are living with homelessness, who are living in situations where their caregivers care about them, but they are not able to fully protect them in spite of their best efforts.

I’ll add one other thing, and that is we’ve learned something since Sandy Hook that is very important. A group of colleagues and I did a study where we identified that not only can traumatic events lead to PTSD and complex PTSD, but benevolent events — events that build a child’s sense of hope, of connection, of community, of safety and security — that those kinds of events are enormously important to protect children. They don’t prevent the development of PTSD if a child experiences trauma, but they make recovery much more possible. And so we all are thinking a great deal more about, how can we infuse the kind of benevolent experiences that children need for their development into their lives on a day-to-day basis and not just when trauma happens.

Chris: Excellent.

Carolyn: Interesting.

Chris: Thank you very much, Dr. Julian Ford, and Dr. Rocio Chang, both UConn Health clinical psychologists, thank you so much for joining us.

That is our time for today. For Dr. Chang, Dr. Ford and Carolyn Pennington. I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe to you can catch us next time, and please share with a friend.