So good afternoon, everyone. I'm Dr. David Stifler on behalf of the American Academy of Addiction Psychiatry. Welcome to today's webinar, which is the third in this academic year of us hosting the Advanced Addiction Psychotherapy Curriculum. This is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty, and this is hosted in partnership with Oregon Health and Science University and New York University. We're excited you could join us today and to offer you these live trainings that'll be held on the second Wednesday of each month from 5.30 to 7 p.m. Eastern time. Today's presentation will focus on trauma psychotherapy. Our next presentation will be Wednesday, November 11th, when Dr. Robert Weiss will be discussing integrated group therapy. Please check the AAA website for updates on other upcoming speakers. A few housekeeping items before we get started. You can feel free to ask questions anytime in the presentation by using the chat box on your control panel, or you can also submit questions into the Q&A section. We will have time at the end for our speaker to answer questions, but also Dr. Blazes and I might kind of bring the questions up during the presentation as Dr. Berkman was looking for live questions and discussion, which we're looking forward to. And then finally, after the session, you can claim credit by logging into your AAAP account and accessing this course. And please complete the evaluation and follow the prompts provided to claim your credit. And I'll turn it over to you, Dr. Blazes. Thank you, David. And again, I'm Chris Blazes from Oregon Health and Science University, and I'm excited to introduce Dr. Christine Berkman, who is associate clinical professor at the University of California, San Francisco, and is an attending psychologist at the San Francisco VA healthcare system. She specializes in the assessment and treatment of substance use disorders and traumatic stress with a focus on developmental and complex trauma, as well as moral injury. She uses an integrated approach with both individual and group psychotherapies, often pulling on psychodynamic theories to inform her conceptualization and flexibly applies evidence-based psychotherapies to best meet the needs of the veterans she treats in the substance use and PTSD clinic. Her research interests have focused primarily on developing a novel treatment to address moral injury amongst combat veterans who have killed in war called the impact of killing. She's also currently examining whether race-based stress and trauma are adequately addressed by existing evidence-based psychotherapies for PTSD. Dr. Berkman has supervised dozens of psychology, psychiatry, and social work trainees, including me at my time at UCSF, and was recently awarded the American Psychological Association's Division 18 Award for Excellence in Mentoring. Later this fall, she and colleagues are releasing a book that's entitled Group Approaches to Treating Traumatic Stress, a clinical handbook. She's an advocate for flexible and tailored psychotherapy to address the myriad of challenges often confronted amongst those struggling with addiction and traumatic stress. And then, I just also just want to add that she was part of the inspiration for starting this series because she kind of rekindled my interest in psychodynamics and psychoanalytic principles and how they can be applied in even brief encounters through kind of my interactions with her and in group therapy. So I'm grateful that she's with us today, and thank you, Dr. Berkman. Thank you. Thanks for the warm welcome, and I'm so glad to be here. And I know one way I kind of like to work, and I think it's reflective in how I like to work with clients as well, but collaboration and back and forth I think makes these sessions usually go a lot better, and I know it can be challenging in a virtual format, but I'm really going to encourage folks to ask questions, and I might ask you guys questions, so I'm hoping you're going to be willing to chime in and let me know kind of your experiences because I'm always curious about what people's training looks like before we jump into some things. So I want to make sure that when we're talking about approaching kind of how do you approach working with trauma that I have a good sense of what your interests and backgrounds are. So I think I'll just share with you kind of what I had in mind in terms of potential directions that we could go today. So one place I always like to start when I think about, you know, how do you approach trauma psychotherapy is let's understand the trauma exposure that we're dealing with well beyond kind of the diagnostic criteria for PTSD. I think most folks understand that there's a whole range of trauma responses that show up that may or may not fit that diagnosis, so I want you to spend a little bit of time on trauma profiles. I'm just curious, you guys, I don't know if you can raise hands or comment in the box, but how many people are familiar with complex trauma? I'm hoping most people, not everybody. Are there hands? I see one hand, two out of ten right now. Two out of ten, okay. How about developmental trauma? How many people are familiar with that concept or that framework, developmental trauma? Is that relatively new? I see one, is that one hand? One thumbs up. If anybody is familiar with developmental trauma, would you be willing to raise your hand so we can unmute you and just share kind of what you know about it or how you've learned of it? Is there a way to unmute people? I see two hands. Yeah, we can do that. Hi, I'm Hillary, Addiction Psych Fellow with Chris. So my experience with developmental trauma is really just people with usually profound sexual abuse in early childhood, and then that has long lasting repercussions around their personality structure, how they form relationships and navigate just all these different components of adult function. Okay, great. So definitely experience with kind of early childhood sexual abuse and is the term developmental trauma versus complex trauma is that something people are familiar with the difference. I'm not actually I, I feel like I see it all the time but I don't have precise definitions. This is very helpful because that means that if we go through it, it won't be a waste of time you guys might be newer information people which would be great. Okay, next, next question is, are people familiar with phase based approaches to trauma. So that's something people have heard before phase based approaches to trauma. No. I don't see any hands. Okay, well this is exciting I think most of this is going to be relatively new unless. Oh, no. Okay, good. So I'm just getting used to the format guys thanks for being patient with me. Great. And then, so I'd like to try to go through kind of what are various trauma profiles and what are some similar, but different presentations I want to talk a little bit about moral injury and race based trauma just so that we can get like a broad range of all the ways trauma might show up with people you're working with, because before we pick an intervention or a series of interventions I think it's really important to understand what we're up against. Knowing that so many interventions are really designed for traditional PTSD. At least a lot of our evidence based psychotherapies, I think it's important to kind of get a sense of the strengths and limitations of that. And then talk a little bit about phase based approach with trauma survivors and I think, you know, almost everything I think about is in terms of co occurring PTSD and addiction just because that's kind of where I work and knowing this audience I figured here is to really focus on people struggling with addiction who also have trauma. And then for the end of the group kind of depending on how this goes. I'm curious how many people feel like they get more training and individual versus group psychotherapy. So do people feel like they get a fair amount of training and individual psychotherapy. I can just see a show of hands. Like yes I get a lot of training and individual psychotherapy. Okay. Awesome. Okay, how about group. How many people are getting experience in group psychotherapy. Less. Alright, so I'm just going to ask because it will help me manage time are people interested in learning more about managing trauma and group psychotherapy. If that's something that you haven't gotten to have as much experience with. Is that of interest to people in the audience. I see one thumb two thumbs. Okay. Can I ask if anybody's brave enough to share if they don't like group and aren't interested in learning how to run a group, if they'd be willing to speak up and share about that. You're all like group enthusiasts in the shadows. Okay. All right, well then we'll try to see how it goes. Can I can I ask what kind of groups have you guys done. Anybody willing to shout out or write in the chat what kind of groups you guys have participated in. Oh, there's no hand reaction for now. Gotcha. That does make it hard to have a conversation. All right, are people able to are you guys able to write into a chat psychodynamic group okay great and patient groups. The diagnosis. This is great. Okay, here we go. Okay. Alright, so it looks like our has anybody done like a process group with my co residents, or so you've participated in a group yourself okay cool. Has anybody been part of like skills based groups like CBT type groups. No. Okay. Yes. Good combination. Okay, well let's. Oh mothers and babies. Oh, that's interesting. Yes, he is more fun and groups awesome matrix groups here at the VA great dbt and okay dbt and 12 step. I'd love to hear the CBT is more funding groups I'm going to Carla I hope you're okay with this but I'm going to come back to you when we get to groups because I want to know more about your comment. I don't think you're alone in that thought. Okay, let's, let's go ahead and jump in unless there's any questions before I get started about trauma psychotherapy, just please put them in the chat. I know it's hard in a virtual setting but I really do want to hear from from you guys about what you're interested in what you'd like to know. So, let's talk trauma profiles. I think most folks know that we really only had a diagnosis of PTSD around the 1980s I think our Vietnam veterans were essential in helping us understand a lot of what they were experiencing and going through in previous kind of combat situations was referred to a shell shock or neuroses, and a lot of research in combat veterans of the Vietnam era but as well as motor vehicle accidents and sexual assault kind of led to the diagnosis of PTSD, which I think is very interesting is that even though they did work with combat veterans there was still this emphasis on a single event trauma, and that there was this relatively cohesive sense of self, where people were regulating their emotions and thoughts, and that trauma disrupted that and resulted in intrusive memories and emotions avoidance negative alterations and cognition and mood and then the hyper arousal symptoms that I think we're all familiar with. Later on, and closer to the 90s there's this recognition that the single incident event wasn't going to capture what a lot of people experienced. So, Judith Herman if you haven't read trauma and recovery it's a highly recommended book, it's kind of a seminal piece and anybody who's doing trauma work for trauma psychotherapy work and it started to lay the groundwork for the idea of a phase based model of care. And the idea is that people who are exposed to prolonged experiences of interpersonal trauma in particular. So childhood trauma interpersonal violence torture and I would argue, war. For many people who were there for a very long time. You have a much more pervasive set of symptoms that that go beyond kind of the four clusters that I mentioned before that they captured in the more traditional PTSD model, and you start to experience interpersonal difficulties shifts in sense of meaning. Oh, sorry I need to close that out. Senses of meaning and purpose. And so the idea being that complex trauma looks different than PTSD, the ISD 11 is including complex PTSD or complex trauma, which is a step forward. It wasn't originally included in the DSM diagnosis but now there is more of a recognition that this is a separate condition. I think what's most important to kind of hang on to here is when you're trying to differentiate between complex trauma and say like borderline personality disorder so we know experiences of childhood sexual abuse in particular, can be a precursor to borderline personality disorder. But that's not necessarily. They're not the same thing. So borderline personality disorder and complex trauma you don't want to interchange them. A big difference is that with complex PTSD there's there's no variability in sense of self, it is a persistent diminished defeated worthless sense of self, and that's something that's really important to kind of pick up and hang on to, because there may be changes in personality structure that happened from adverse early childhood events including trauma. But we want to just try to kind of keep keep these things as clear and clean as possible even though sometimes there's there's overlap, but diminished defeated worthless sense of self and then a lot of feelings of shame, guilt and failure. And then I think as mentioned earlier, by one of our participants, the difficulty in sustaining relationships and feeling close to others, that these are all kind of pieces that came in that are more than PTSD kind of simple version. So I'm going to go ahead and take something that already got complex and it's in the title and I'm going to make it more complex, because all of this was developed on adult populations so people were really looking at adults who had experienced traumatic experiences of abuse they were interviewing adults, after they had survived childhood abuse or torture or interpersonal violence, what was happening in the child field, the child psychology psychiatry field was people were working with children who weren't just exposed to trauma that was part of it, but they were also exposed to a whole range of adverse childhood experiences. And this doesn't just mean, you know, physical abuse sexual abuse, emotional abuse but it could also mean neglect and neglect could happen due to parents having to work multiple jobs because of poverty, it could happen because of parents who had substance use disorders, and we're really checked out and not fully present. impoverished communities that didn't have access to the same things. And so what they were seeing is in lifetime as children were growing up, it wasn't so much that they were being that the trauma was kind of changing their perspective of self others in the child, it was forming it, it was shaping it. So what happens to the human brain the sense of self. If you're constantly chronically exposed to adverse and traumatic events for a long period of time, as you're developing and importantly, it's the context. So, what people were thinking about as developmental trauma being different than complex trauma is that it happened in childhood and early on infancy even that it was prolonged. And importantly that the caregiver, or members of the caregiving community for the perpetrator. And so when we think about kind of object relations and how do people identify who they are what they need how they feel so much of that is what's reflected in the caregiver. So how they develop a sense of safety a sense of knowing what they're feeling and thinking. It's attention and reflection of the caregiver, it's the ability to kind of know when they're tired when they're hungry, that they have protection when they need it and so when these things are disrupted or worse when the caregiver is actually causing harm and fear and pain. How they develop the ability to even understand emotions communicate emotions regulate emotions, how they understand the ability to communicate needs and negotiate relationships are so profoundly shaped in a way that we're not really talking about a market shift and perspective. So when we think about complex trauma being there's a shift in perspective, perspective, there's a sense of betrayal. When we're thinking about developmental trauma. It's like it was never there in the first place, there was never necessarily safety or a sense of integrated self in the first place so there there's kind of even bigger, more severe ramifications. Is that making sense. Are we okay, I can only see two heads so thank you Chris and David for nodding so I could kind of track. What I think is really important to kind of pay attention to, especially when we're getting to know our clients is if we have suspicion that they have a lot of trauma in terms of their upbringing in addition to maybe adult trauma, whether it's combat or assaults or violent relationships. If we know that there were adverse experiences or abuse and neglect in childhood, we also really want to kind of place them in a system and start to have an understanding of where their social elements that made the ability to recover even more complicated because influence how they respond to caregiving and how they respond to your status as a provider. If you're part of a system that's there to help and provide support. What were their experiences like with that previously, how was their behavior responded to in their local schools, how are they kind of dealt with by teachers and counselors and and social welfare and legal services. Did their race, ethnicity, religion, any kind of cultural features that that impact, how they were received and how they responded to my graduate training was in Chicago and I worked with Child Protective Services we were looking at developmental trauma, and I can absolutely tell you that families were given very different options and resources depending on race and neighborhood that they lived in. And when we think about that when we think about that a lot of kind of traumatized individuals who are often people of color or people who have very limited resources recent immigrants language barriers. What is the kind of compounded ramification of not just the trauma, but the response of the system. So are things misdiagnosed, are they caught our children blamed for behavioral problems that are really trauma related. How are they pulled their parents, their parents role in the situation is. So I know I'm bringing in a lot of things I'm making something complicated even more complicated but I'm trying to get out is try to understand your clients experience of what was the nature of the trauma that they experienced, if it was childhood trauma, and then more information about like, you know, where were they able to get help, how did their family make sense of what was happening to them, etc. I think about, you know, in particular when you think about the role of neglect, I mentioned substance use I mentioned working multiple jobs one thing I didn't mention was massive incarceration, and the impact that has had on individuals growing up without access to parents that maybe have been incarcerated for very long periods of time. So all of this to say, find out. I'm going backwards. Hold on. Find out as best you can, what level of trauma, are you working with. I think most people are probably most familiar and comfortable with more traditional more often than not single incident focused PTSD model, I think that's where a lot of our measures are based on we have the PCL five that we use all the time at the VA and the idea is that we're really tracking these clusters of symptoms to see if PTSD is getting better or worse. There's a lot of people who work in clinics where you have folks who show more complex trauma. There's a recognition that there may be a lot of co occurring diagnoses in addition to maybe PTSD, there's also depression, there may be personality disorders, there may be additional kind of anxiety disorders that show up as well as substance use. But I think what I'm trying to kind of just bring in and we could spend a lot of time teasing apart the difference between complex and developmental trauma, but part of why I want to try to bring this in is when you're working with people, especially people who maybe started using substances at an early age, you're really trying to get a sense of what are their internal resources. So many of our treatment interventions are based on assumptions that people have the ability to identify, name, communicate what they're thinking and feeling. And for many individuals, that can be really tricky. That could be because of complex trauma where there was a major kind of interpersonal trauma, sense of betrayal, and they have a lot of difficulty in trusting. So they might have difficulty wanting to share because that's vulnerable and it may be hard to kind of trust others. You as a provider, you may actually show warmth and empathy. And while that sounds like that's a good thing, that may freak people out. If the person who previously showed them warmth and empathy then violated that trust, that could complicate your relationship. So the idea of kind of understanding the complexity of what kind of trauma are they showing up with can be really helpful in kind of helping you figure out how you should pace, how much information do you need to make sure they understand about what you're doing and why. And with developmental, what I think we've been finding is it's not always obvious. I think for some people, I'm putting these three trauma profiles up, but I rarely can walk into a room and be like, oh, that person has developmental trauma. I think that's something that you start to kind of wonder about as you start working with somebody. I think it's easier to get a sense of somebody who's got more simple PTSD versus complex trauma through a diagnostic interview. I think the developmental trauma piece shows up during the work. And that's where you're really getting a sense that this isn't an adaptation. This was like an absence of something getting developed. A stable sense of self, a sense of what is harmful or not harmful. So trying to make it as simple as possible. If you've been in a situation where you're working with somebody and you ask what you think is a relatively simple question and you get kind of a deer in the headlights, a real sense of confusion that they don't understand that you're responding to a situation that you would think they'd respond to. So like they can't pick up on what is abuse, what is hostile, what is harmful. And you're like, oh, that sounds like that might've been really hard for you. And you kind of need that blank stare. You might be tiptoeing into the territory of developmental trauma. That it's not as clear and integrated as a picture as complex trauma. So I'm gonna pause there for a minute because I just wanna make space for people to ask questions about these trauma profiles. Yeah. Does it? Yeah. Can you comment on like reactive attachment disorder and is that a type of developmental trauma that's more severe or how does that apply here? Reactive attachment disorder? Yeah. Yeah. I think, I think it depends on who you ask Chris. I think it can be. Like I think there's a lot of things that can disrupt attachment. And children, I think what you're really looking for is over time, is there, are there challenges across multiple domains if that makes sense? So if somebody with reactive attachment disorder seems to have the ability to kind of process information, it may be distinct from something more like a developmental trauma diagnosis. Whereas somebody with developmental trauma, at least the way they were proposing it, it got rejected by the way from DSM-5, but the way they were proposing it is that there really is severe deficits across many, many domains. The thing is, yes. One might even predispose someone to get, yeah, I think that's a really good point is that there can be somebody who you'd be like, oh, I think you have developmental trauma and I think you have aspects of complex trauma. And I think that you could definitely meet criteria for PTSD. I think the idea is it's less about, in my mind, it's less about getting the diagnosis exactly right, because I think for most of us, I mean, developmental trauma isn't something that you can bill for, right? But I think you're trying to get a sense of how integrated is somebody. So usually if you're thinking about more of a simple trauma profile, they have a lot of stuff going for them. They have a sense of self, even if that sense of self was horribly impacted by their event or series of events, they have the ability to kind of regulate emotion to a certain extent and process information, have a sense of motivation. And I think as you start to kind of get into these deeper layers or the more complex layers, what I'm hoping I can communicate is that I think you have to kind of shift your expectations around how much work it's gonna take to help them get to the point where they can use the treatment interventions that were developed to treat PTSD. So if somebody's got really profound developmental trauma, they probably have had other experiences that may meet the other two definitions. But what I think it's gonna really mean is they're gonna need a lot of work in learning how to breathe, how to sit with you in a room, how to communicate what they're thinking and feeling, and you're gonna have to use techniques and strategies that are very simplistic. You might need to use almost aspects of like play therapy. I've done walking sessions. I've had people kind of, if you have those sand guns, kind of using sensory techniques to try to actually help them sit with an emotion long enough to be able to slowly get access to it and name what they're feeling in the room. So you might have several sessions of that before you can even get to an intervention that's actually targeting complex trauma around emotion regulation. Something like STAIR or other interventions that really require them to be able to identify and name what's happening to them in that moment. So yes, definitely overlap. But I think what I'm hoping to kind of convey is the earlier, the longer, and depending on who it is, have a lot of humility in approaching trauma work with people kind of going into treatment. Because I think what can often happen is if people seem like, you know, they seem really, oh, they're really bright. They're really smart. We're going to throw them into a highly cognitive kind of very verbally focused intervention. It can go sideways because you're not fully seeing kind of just how limited they are in their ability to actually understand and identify what's happening in their body and emotionally to certain situations. One more quick question, Chris. So in differentiating developmental trauma from borderline personality disorder, do I have it correct that borderline personality disorder is those people can function fairly well except under stress, then they will kind of, you know, devolve into dysfunction. Whereas people with developmental trauma can oftentimes not even arrive at the high level of functioning at any point. Usually, yeah, usually. There are exceptions. Like they might excel really well in like kind of one domain of their life, but you see pretty profound disruption. And usually it's interpersonal, right? So maybe they can function really well at work with certain types of jobs that don't require a lot of dealing with other people. But I think with borderline personality disorder, there's also kind of this added element of fear of abandonment. There's an issue of like, there's some part of them that wants like attachment and connection, right? The strong characteristics of suicidality that may not be present in developmental trauma, I guess is part of what I'm getting at. Like there's things that are very unique to borderline personality disorder that I think have to do with invalidation and the environment that aren't necessarily what's happening in developmental trauma. Like profound neglect is different than an invalidated environment and kind of what gets developed in BPD. So profound neglect, if you think about a kid that's just like no one's ever reflected back to them, they were sad. There's just this complete lack of ability to even recognize what they're experiencing in that moment or have language for it. Does that make sense? Sorry, it might be a hard way to answer it. Has anybody ever worked with somebody where you think there might've been some element of developmental trauma showing up where there just seemed to be like a significant sense of almost like there was a poverty, there was like an absence of kind of this core ability to identify an internal experience or understand? Yeah, and if you have, if you'd be willing to share, that would be really helpful just to make this a little bit more grounded. So Carla, definitely, would you be willing to kind of share your experience at all about what that felt like or looked like to you in the room? I mean, I think that we see these patients all the time, like patients who have a lot of developmental trauma coming in for substance treatment and sorry for the background noise. And I think that I somewhat lazily attributed all to the borderline personality, but it probably is, I think, better reflected in this concept of developmental trauma. Thank you, I appreciate that. Thanks, Carla. I also have some experience and I think with the substance population, maybe you were saying the difficulty with either identifying or talking about, or certainly like sitting with emotion that maybe they're not aware of to begin with. And then if you're trying to, for a lot of people with substance use, if you're thinking about a self-medication angle, right? Identifying the emotion that's hard to cope with and that you're using. And if people, if they can't even have a conversation about what emotions are to begin with, it really takes a lot of work just to get to that place of tolerating emotion in a way that might help with changing some of the substance use. So there's quite a lot, and I mean, it can go on months or a year or longer before you're really even ready to have those conversations that for some people they're ready to have right when they walk in your door. Right, right. I really appreciate that, Dr. Seltzer. I think it is, it's a little, it's humbling and a little daunting. Because when we think about what we're asking of people, it's kind of like tread lightly, right? So for some people, if we push too hard, too fast, and we're like, okay, I'm going to help you feel, I'm going to help you identify what you're feeling and process it and communicate it with me. And we know that if they don't have any sense of competence or mastery or senses like that, they will survive it. We could see a major increase in substance use because that's the only technique or strategy that they've learned and developed. And I think it takes a lot of patience and I would argue a lot of reassurance. I find myself almost like narrating constantly with clients who have this kind of presentation, the importance of just kind of noticing how they're doing in the session with me and just kind of tapping something and then pulling back from it. For example, if I'm asking a question about maybe an argument that they got into with their significant other, and as we start getting to kind of the details of it, they start just seeming very, very sleepy, kind of out of the blue, right? They're just getting incredibly tired and they're kind of crumbled over in their chair. I may just notice, like I notice it looks like you've just kind of gotten overwhelmed with fatigue and tiredness, what's going on in your body right now. And if I can get them to describe that to me, that might be what we do that day. And it might be just helping them connect that there's a response that they're having that's indicating that even talking about a really unpleasant experience with their partner feels like a lot. And so I'm going to validate that they were willing to kind of hang in there with me and get curious with me together about why it was so hard to get through this conversation with me. But I'm also going to provide kind of information about, you know, sometimes that happens. I think it's really great that you're willing to kind of try, maybe we can shift gears and talk a little bit about kind of how we're going to cope after you leave my office today and kind of shift into some sort of concrete coping strategy but that's where you're tapping into an emotion and they're communicating with you indirectly that they're overwhelmed. You don't want to completely ignore it, but you also aren't necessarily going to double down and try to get them to experience the emotion. And that's kind of one example of how you might titrate working with somebody who maybe has more of this developmental model to try to really help them understand we're going to come back at it again next week. And we're going to see if we can get through more of the conversation about this hard thing that happened to you. Oh, we have a question. I'm sorry, I'm getting over a cough. Okay, tangentially, I'm thinking about, oh, should I read it out loud or can people see it in the chat? This may only be tangentially related, but I'm thinking about a young man on an inpatient unit for HI and sociopathy, perhaps not the right term. He was killing small animals and deer and had started desiring to kill people. There was no social connectedness, no awareness of any emotion other than that, other than his, I'm assuming the desire, perhaps desire, and a complete lack of connection to other living things. He had severe neglect in early life and was at the time in foster system with this kind of fall into the, yeah, it could. I think, oh, you cannot see it. Did that, you know, I did that thing where I'm like, oh, I don't know if I should read it out loud or not. So I kind of whisper, read it out loud. Did I get the majority of it out? Did people hear that? Yeah, okay. This is, I think this is a really good question. My gut response is wait and see. I mean, it's kind of like work with them a little bit longer. This is a question I think is going to take a little bit of time to determine whether it's sociopathy or psychopathy or developmental trauma. You know, I think when, I'm just thinking back to kind of what I know about psychopathy and sociopathy, this idea that for some people, it's like, your brain is different. And then for others, it's really the environment that shapes this kind of detachment from other living things. I think, I think the answer is maybe, but I don't know that I've seen in any of the research on developmental trauma or any of the stuff coming out that there was this complete void of ability to connect or ability to feel in the same way with the like killing animals and desire to kill. So that feels like it's leaning a lot more towards psychopathy and sociopathy in my opinion. But I think it's good to wonder. I think there's definitely role for neglect and that, but off the top of my head, I would say that's not really what I've seen. The lack of empathy or the lack of detachment, definitely, but I don't know paired with this desire to kill. And Ryan, do you want to say anything or kind of jump in? Maybe there's more detail or I can answer your question a little bit better. Oh, no, that's great. Okay. Oh, you can't unmute. Okay. All right. Thanks for trying. Okay. I've had too long, longitudinal therapy patients who have struggled to diagnose ultimately say there might be some, yeah, I think I feel very out of my depth with autism. So I can't say that I'm the expert on the autism spectrum. But I think, I mean, I think part of what you're really looking for is, is there like a lack of interest or desire to have any sort of connection versus an inability to. So really looking at capacity because I don't know that. And again, when you say that it's, how do you help somebody maybe learn how to identify what they want? Right. So we're assuming that people can communicate that maybe they, they want connection or they want to have relationships, but you'd want to try to find out do they have the ability to kind of name that and want that, or do they genuinely have kind of a disinterest in connection? And Rachel, if you're able to unmute yourself, please feel free to. I feel so, I feel so sadistic here. I'm like, please communicate and talk to me. And then you can't unmute yourself. So I'm sorry. I was able to, I had a, the host requested I unmute myself. So I did. Okay, great. Thank you. Yeah. And thank you. I, when patients have difficulty identifying their emotions or what's happening or kind of are unclear about what I'm trying to ask them, I have had that experience frequently, I think. And it just sounds like there are a multiple, there are many reasons why people may have that experience. And then what you're saying is over the longer term of the patient, you can get a better idea of, is this a desire, lack of desire? And this is sort of like situational. I'm just trying to. Yeah. Yeah. Or is it a liability? And I think one, one way of doing that is, I mean, just ask more questions about kind of what was modeled. Who did they go to when they were hurt? You know, who did they spend, what did they do for fun? And just try to get some ideas about kind of early on, how did they engage with care, joy, meaning and purpose, as much as you can put that in the context of childhood. I am aware of time, so I'm going to move us, if that's okay, I'm going to move us forward a little bit. I wanted to just include these, we won't go into it in detail, but I'm hoping this is becoming more and more obvious. Just increased emphasis on the importance of recognizing race-based stress and trauma. And I bring it up in particular because there's cognitive processing therapy, which we use a lot, and I've seen it work really, really well for a lot of people. But there are treatments that the kind of underlying assumption is that trauma beliefs. So the shifts in sense of self, others in the world, that those beliefs are distorted. And so I think what that unfortunately can kind of move providers into is telling people who've experienced very real discrimination, harassment, and even assaults for their race is, you don't want to get into a position where you're saying, well, but do all white people do that? Or do all police officers do that? Like there can be something incredibly invalidating if you use similar techniques that you might use with somebody who had an isolated assault incident, where it didn't seem to be race-based than if you did. So I add this again, just as kind of a, you want to be really thoughtful about all the different pieces that are showing up in your trauma presentation before deciding what kind of intervention you want to use. More importantly, that you would use the intervention, but you need to adapt it and be thoughtful about how you're using it. And moral injury, it's a similar thing. So similar thing in terms of the treatment that I just mentioned. So there's really two definitions of moral injury. The one that's used most frequently is the self-betrayal. And that's the idea of perpetrating, failing to prevent, or bearing witness to, or learning of acts that transgress deeply held moral beliefs and expectations. And so I think, you know, thinking about working with combat veterans, sometimes well-intentioned, you're trying to kind of flesh out context and saying, well, but what could you have done? And there's limits. And there are experiences that people have where they did cross a line. They did cross a moral line and did something, but they didn't have to do, or even if they were ordered to do it, they knew it was wrong. And by kind of trying to make it make sense, there's another version of invalidating where you're kind of, you're not acknowledging and honoring the morality that was injured in a way. So again, I put these up just to kind of point out, just like with the trauma profile slide before, you want to be really mindful of what level of kind of integration is the person that I'm working with have so that we can take, you know, make use of how does that make you feel or what emotions popped up for you when this event happened? What thoughts did you have? So many of our interventions expect people to be able to do that. And these are all the ways that I think it's important to kind of pay attention to where do you need to flex and make sure that you're really thinking about how are you using the evidence-based psychotherapies for PTSD. People, yeah. Any questions about race-based stress or moral injury? I'm looking at the chat right now. Okay, let's keep going because we've got more we can do. So the main thing is just to try to establish a baseline of functioning across domains. So when you're working with somebody, and it's really hard because if they're still actively using substances, this gets very, very murky, right? You're really trying to kind of pull apart what's going on. But I think what can be helpful and I've found helpful over the years is once you're working with somebody and they have a little bit of stability in terms of their use, and you're really trying to get clarity around why are they struggling so much with answering questions about how they're thinking and feeling when you're moving into, and we'll talk about it in phase-based care, when you're moving into experiences of you're trying to help them have self-intimacy where they really start to get to know who they are internally. If they struggle with that, keep asking questions and try to get a sense if there's a sense of they had a relatively intact sense of self that then got horribly like distorted, damaged, or is this somebody who they've never really had a sense of safety, they've never really had a sense of trust, and you're going to have to go a lot slower and kind of start with the basics. And that can include what are you feeling in your body? Let's take a few deep breaths. And I hope it doesn't sound infantilizing because that's definitely not the idea at all. But if you think about somebody who never learned how to do that as adults, we're going to have to slow down and help teach them how to do that. And that treatment's going to be slow. What I think is really important is we go all the way back to that slide about complex PTSD is this idea of diminished sense of self. So feeling worthless, broken, devalued. And I think one thing that I always worry about with people coming in for trauma treatment, especially if they started using substances at a really young age is I really want to know what the trauma profile is because we are communicating that we can help you and that you're going to get better. And if the treatments that we offer, the evidence-based treatments that we offer, if we throw them into a really excellent seeking safety group with great skills and they can't seem to hang, they can't tolerate being in the group, they don't understand the skills that are being implemented and they feel like a failure, they feel incompetent, we could be adding to their sense of shame. We could be adding to their sense of brokenness. And so I think if you get a sense that, wow, there's a lot of really profound early trauma here, the key takeaway is make sure you're communicating that with your patient so that it's not just about your expectations shifting to, we're going to need to have a lot of work. It's about a lot of validation of, yeah, it's really hard to know what you're thinking and feeling. Like, I understand that that sounds like a simple question, but given your experiences, I don't think it's a simple answer. So we're going to slow down and take our time because you really don't want to have a client leave feeling like they failed therapy. You want to kind of take ownership for that and say, we need to make the therapy work for your experiences. Okay. So models of care. This is why so many models of care, I try to separate out substance use and trauma. They're hard. They have very severe symptoms. They often have comorbidities. There's a lot of dropout. They're more likely to relapse that fear of, I'm going to make them feel more emotions than they're going to use. It's a real fear because it could happen. And I think people get frustrated. I think a lot of providers want to feel useful. They want to feel like they're helping. And it can be really, really challenging when you're trying to work with somebody who struggles to kind of tell you how much they're actually using, can't really tell you what they're thinking or feeling, but does have kind of these huge emotions that are hard to regulate and manage. And as a provider, that can be really challenging. So what historically we've seen is the top two models, much more of a sequential model. Like, well, they're not ready for PTSD treatment, so we need to get them totally abstinent. And I hope that's not the model that's out there predominantly, but I have to tell you, I just shared with a provider, we had a client who was doing trauma work with them, and this is a provider outside of addiction. And when he relapsed, it was a relatively short relapse. And he came back, which we found a huge, you know, the arts side, the addiction side, found it to be a huge success. We're like, this is awesome, only three days, and he's coming back. That's faster. He's developing more trust. But the non-addiction provider was like, well, maybe we should wait a year for him being sober because we're working on developing intimate relationships. And I think that it would be better for him if he was sober for a year. So I think there's still this sense that somebody has to be totally sober to tolerate and be able to handle trauma work. And I'm hoping, and maybe we can take a poll, I know it's kind of hard to communicate virtually, but I'm hoping that's not the spirit of folks here, that we have to treat trauma to kind of also address the addiction. So I think other people do the parallel and concurrent model where they might be saying, like, okay, we definitely need to address both, but we've got our experts in trauma, our experts in addiction, and we're going to kind of keep them separate. That's better to me than sequential. I'd much rather have that. But there are risks in stuff getting lost in translation. And if we're working with really complicated people, and we know that shame is extremely common in both trauma and addiction, avoidance is common in trauma and addiction, and struggling to be kind of honest and communicate is a huge kind of factor that's asking a lot of the client to manage what's happening in both sides of the street. So what's often recommended is the integrated model. And that's kind of the approach that I think works best. And I think it's getting more popular. I mean, is that what most people are finding in where they're working is that people take an integrated approach, if you could just raise your hand if that's the case. Thumbs. One thumb. Okay. Two thumbs. All right, good. Well, if it's not, I'm going to keep advocating for it, because I think it's the safest way to treat co-occurring. And my example for that would be, and this is going into the phase-based model of treatment. It's not like you throw somebody into the deep end, and you throw them into an exposure-based trauma-focused treatment right away where we expect them to be able to tolerate everything all at once. But if you're able to build some skills and help somebody at least reduce their use and get to a level where you feel like they have additional coping skills besides substances, then even if you engage in a trauma-focused treatment, and they relapse, you can use that relapse, because ideally, there's going to be enough rapport and attachment and safety that you've established that they're going to come tell you about it, that you'll be able to use that relapse as an incredibly important opportunity, not just to understand the relationship between the use and the PTSD symptom that was triggered, but you're going to have this experience of destigmatization. You're going to hopefully reduce shame. You're going to validate that this is what happens. This is what they're living with every day. And you're going to kind of rebuild that trust, not just the trust between you as a provider and them that they can tell you about this, and you're not going to reject them or tell them they're not ready, but also in themselves, that even if they stumble, even if they falter, that they can trust themselves to kind of keep coming to treatment and keep working on it and sticking with it versus what I think is more often to happen in the top two models, which is attrition. Somebody's like, oh, I can't handle trauma work, and so they drop out, or I'm not ready to stop using, so they just don't tell their PTSD provider about it. And what we're actually wanting is the messier version where they stumble in both areas, but they're stumbling publicly and with you and in a way where you can create a safe and kind of nonjudgmental understanding space where you help them work through it at the same time. These are some of the concerns. I'm just looking at the time. Yeah, these are some of the concerns that people have about doing trauma work with folks who are still actively using, and it's not without merit, right? We want to keep people safe, so I'm often telling people the most important thing to me is keeping you safe, and I think for a lot of folks, that means not using, certainly not using the way that's brought them into working with you, but I do think there is a fear of not kind of allowing clients to practice coping with really hard things and just hoping that they don't get triggered to not kind of disrupt their recovery or their phase of reduced use or abstinence, and I don't know how much of that is kind of people genuinely feeling, like talking about trauma is going to break their client, and how much of that is just insufficient trauma training where people feel like they don't feel really comfortable knowing how to handle somebody who's flooding or dissociating, and so they're not going to kind of go into that because they're not sure how they're going to respond in the moment, so I think it's always really helpful to just, whenever you can, get additional training in managing trauma if you're going to work with SUD, and as much as we can, get people who are trained in trauma to come kind of find home clinics and addiction programs because we need these two sides talking to each other a lot. Okay, so have people, I think I already asked, but Judith Herman's trauma and recovery, when she developed, like this is a big part of why we have a concept of complex PTSD and complex trauma, the phase-based model of recovery really briefly is you focus on stabilization first. You don't just throw somebody into let's talk about all the details of the worst thing that ever happened to you. You really start slow by helping them understand what's happening to them and why, and you work on coping skills, so that might look like grounding techniques, so breathing, using tactile objects, counting things in the room, that sort of thing, and the whole idea is to try to help them regulate and learn how to manage intense emotions in the moment before you move them into processing, and the idea of trauma processing, which usually involves cognitive restructuring or exposure, so the two, I would say now the three most commonly used would be like cognitive processing therapy, prolonged exposure, and then EMDR is you're trying to consolidate the memory because it often is patchy or distorted in a trauma memory, and there is often a fear response that is overly rigid, so you're trying to break associations that aren't particularly relevant, so it makes sense to be afraid of the specific person who hurt you, but if that fear generalized to I'm afraid of all cars or all parking garages or all, you know, people with brown hair, their ability to function could get very, very challenging, so you're really trying to pinpoint and narrow the event itself so that they don't have all of these generalized symptoms that kind of completely inhibit their life, and then the final phase, which I think is really important because I think there's so much emphasis on symptom reduction and not always a lot of emphasis on quality of life improvement, so not just getting symptoms down, but are they actually re-engaging in connection, and with interpersonal trauma, I think this is huge. Are we helping them develop safe and healthy relationships? Are they getting joy out of being connected? Do they have a sense of meaning and purpose? Are we able to take kind of this view, even with really profound, I mean, profound trauma, are they able to kind of rewrite the narrative of why what happened to them happened to them and who they are as a result into something with more kind of post-traumatic growth and resilience? The bottom model was actually based on an article written by the chief of addiction here for many, many years at San Francisco VA, Peter Banas, where a lot of programs were just kicking people out when they relapsed, and at the time, he was identifying you really need to develop a phase-based model of addiction to make room for what's needed to kind of maintain abstinence, because people could maybe, you know, bear it for a while, but then they'd relapse, so it's really looking at what's necessary to maintain longer-term abstinence or longer-term recovery, and on the bottom row, so looking at that is the reduction of the abstinence, so kind of acknowledging that the substance use is out of control and what are some of the concrete coping strategies, and for a lot of our folks, you know, the idea of establishing safety probably involves psychosocial stabilization. You need to kind of move them out of areas that are super high-triggering where they're going to constantly have access to use, if possible, and develop new sober supports. Similarly, I mean, similar and different, but your processing, so the affect part is once you get used at least down, how do we help people become more aware of their internal state? This can be very complicated based on the trauma profiles I just went through, but after a lot of years of numbing through substance use, this is going to take a while to learn what are they thinking and feeling in the moment, so I think people have used things like HALT and recovery programs. This is all designed to kind of increase awareness and ability to connect to affect, and you're really trying to help people understand the connections of what felt like an automatic thing is now something that they're able to pull apart, and then finally the stage of intimacy where they're trying to, you think about where the go-to person to help soothe them is not a substance. It's a human being. It's a sense of meaning and purpose. It's something besides a substance that's going to allow them to feel close or connected or to, you know, identify something beyond themselves, as well as kind of reconcile loss, so the grieving piece that's necessary for both of these. When you're working with co-occurring recognition of just that, they're going to go back and forth. This isn't linear, so you're going to have people who might work on stabilization and trauma, but if you've got a really serious addiction, you're going to be in the stabilization phase for a while, and that, say, you get them kind of to affect or intimacy and addiction phase, the bottom row, so you start doing more of the stabilization and trauma, and you move them into a more focused exposure-based treatment, you may need to go back and kind of redo some of the stages that are happening in the bottom row, if that makes sense. You might bounce between these things, but you're kind of always wanting to understand, if you think about it in a phase-based, if something's not working in the processing phase, you want to ask yourself, have they achieved what we're asking them to do in the stabilization phase? If they're struggling, say they're clean and sober, they're abstinent, they've gone through a trauma-focused treatment, but they're really struggling with integration or intimacy, what's missing in kind of these other phases that are holding them back or preventing them from making continued growth in this final phase? So I think the framework can be really helpful when we're scratching our heads about why somebody's not getting better. Checking the time again, I think we're doing okay. I'm going to pause there for a second before I go to potential benefits and drawbacks of this model. Does anybody have any questions? Is this totally new information to you, or is this something that you guys have seen before in other lectures or your training? So there's one question, Hilary asked, do you have advice for preferred models in residential recovery settings? I've had a few patients in residential who want to focus primarily on their trauma, even early on to maximize their time in recovery, but it feels very early with their difficulty with emotional regulation in the first 30 days of sobriety. Yeah, really, really good question. And one of the hardest things to do is throw brakes on people, but I think it's essential. So I like STAIR. Some programs in residential STAIR, DBT, in terms of kind of the structured treatment of all ways to help them manage emotion regulation, but it's not just emotion regulation. It's emotion regulation, it's interpersonal effectiveness, it's communication. And I think the hardest thing to do is to not squash the motivation for them to deal with their trauma, because they're ready. They're in a contained environment. They want to make the most out of it because they have 30 days and they don't have access to substances, so they're ready. But I think what we're trying to communicate is to have humility for the trauma. So I think kind of there's that early, like, oh, I'm not using now, so now I can take care of it. And it's like, you've been using for so long because the trauma deserves space and time and kind of the attention that it needs. So if this was really easy, if you could get this like sorted out in 30 days, I don't know that you would be using as much as you have been. So it's really trying to help them understand trauma work doesn't just mean diving in and talking about every detail. Trauma work, really essential, maybe some of the most essential trauma work is learning how to know what you're thinking and feeling in the moment. And that may disappoint people, but I think this is a big characteristic of, trying to be fair, but both addiction and trauma. But I think the addiction component is I want it yesterday. So there's that strong sense of urgency of I now know I have this issue, I want to take care of it and I want it wrapped up before I leave here in 30 days. And that's just not going to be the case. And so it's really trying to help them set expectations of let's really set the foundation and get the most out of this. And the best time that we can develop these skills are when you have a period of time where you can really practice and focus when you're sober. So you really want to kind of hype up how it's an ideal environment in residential to really triple down on developing skills. And that the next step is going to be making sure that they can use those skills when they leave the residential facility and you'd probably encourage an intensive outpatient. But that's going to be the trick is that you really want them to practice those skills in a contained space first and then in real life so that when they start to kind of introduce more trauma material, they're going to be prepared. Because I've routinely seen people who want to do the work and the facility allows them to, and they do a huge deep dive. And then it's a mess when they come back, they're using really heavily and they're scared of trauma work. And that's not what we want. We don't want people to then kind of not want to deal with trauma because they learn that I can't handle trauma work. I was in the highest level of care you can have. And it was too much. Does that answer your question? That was super helpful. Especially I like the phase-based as a framework too of really focusing on the stabilization portion and then helping them prepare to practice that outside residential as well. And then we can start the processing of the integration phases as well. Yeah. And I think one thing that can also help, I'm just like picturing myself in the room with somebody who's wanting to do this, right? Is I think there is, I'm actually looking at the bottom row when you look at kind of the reconcile loss. I think there's a moment there to even practice a little bit of grief. Like they're finally sober, they're in a residential facility. And like it's, I would encourage you to actually, if you can get them on board with the stabilization piece, but also making room for like, and it's so sad that you've been holding this for so long and I'm so glad that you're ready and we're gonna get to it. But I know that there may be a lot of sadness in the fact that you haven't had the opportunity to really heal because of the addiction. So I think that is an element. We really wanna make sure that they're aware that part of helping them get to a place of processing trauma is really acknowledging kind of the cost and the ways the addiction has really inhibited their ability to heal from the trauma. And that's hard, that's painful. Any other questions? I have a quick one. Yeah. Oh, someone else is going, go ahead. Well, I was just gonna say that like with the processing phase, with some of the experiential therapies or whatnot, and we include EMDR in that. In my mind, I always think that EMDR is a little safer, has less capacity to destabilize things than some of the other exposure-based traumas. Do you think that's true? I don't know. I think that's a really good research question. Okay. So I'd like to know. I'd like to know. I mean, I guess anecdotally, I've seen people decompensate across the board with all types of trauma exposure therapies, but I've also seen them decompensate by not offering trauma exposure therapies. So I think that's the really tricky piece is we're always looking for the safest way to go. But I think if I'm being really, really honest, as a provider, it's always scary to approach trauma with somebody who has an addiction that's nearly killed them. So I'm not sure any of it's totally safe. Okay. Thank you. Yeah. Oh. Other questions? Okay. I'm gonna just pop forward a little bit. And Chris, actually, this comes to your, I mean, another area for more research. Like I'd love to see kind of among, especially amongst populations of people with SUD, is there any evidence that some trauma-focused treatments are better in the sense of fewer relapses, maintained some level of recovery? Similarly, with the phase-based model, we don't have a lot of great research to prove one's better than the other. A lot of it's anecdotal. And you do think about like, what makes it hard to study this is, it's attrition. So it's really hard to study people who aren't showing up or who aren't there. So we do know that there's, I mean, talking to providers all over the country, especially at VA systems, there's clinics where there is no stabilization. You get PE, CPT, maybe EMDR, but that's it. Those are your options. If you want trauma treatment, that's what you're offered. And you're offered 12 sessions of it. And most of the time in those systems, they'll have some cutoff of how much substance use you're allowed to have, or they'll request abstinence. So I think when you're looking at kind of results of, well, the evidence is really good that you should just throw somebody into a processing treatment right away. I always get skeptical about who's in the study, who's in the research. Because I think so many of the folks that we work with who have co-occurring conditions, they're either not eligible, they drop out. And so I think that's really challenging. But I will say, there are situations, and I know I'm certainly guilty of it, where we can collude in avoidance. You start out with stabilization, and if you have a heart-wrenching journey with somebody where multiple hospitalizations, they almost die multiple times, their addiction is just unbelievable, and you survive that with them, and they're in a better space, it's really hard to knowingly kind of increase their distress and jeopardize that. So I think it's really hard for clinicians to move out of the stabilization phase into the processing phase, really, really hard. And with that, both of you can get stuck, and this is as good as it's going to get, this is as safe as we can get it, let's keep it here. And I think that's where having a team is really helpful. And I think to a certain extent, having fresh eyes, having kind of periods of treatment can be helpful because working with a different provider, maybe in that phase, they'll have different expectations. They'll be able to hold different levels of hope for somebody if it's just too hard for that provider to kind of move into the processing. So I think that can be really challenging. And I also think progress can be really slow. So having humility, communicating how long things are going to take, I think depending on the system that you're in, one, some systems that's not possible. They just don't offer that much coverage. They don't offer that much access to care. So it's really trying to be strategic about what's going to make the most sense with however many sessions we have. But even if you have systems like the VA that are still allowing kind of very long-term care, you can get fatigue. You can get treatment fatigue where the client really feels like they're making really minimal gains and motivation can really drop. So I think it's being mindful of that and being aware of that. I will still say I think the benefits outweigh the drawbacks because I think when you approach it in that way, you are going to, you know, on the surface, it may look more expensive. It takes more time. It takes more staffing, but I think ultimately there are fewer ER visits. There are fewer crises. There's more employment. There's less legal involvement when you approach the kind of two rows of stabilization and the two phase-based models. I think it's really helpful from a counter-transference perspective of helping me kind of remember what all is required to help somebody get through these phases so I don't get frustrated super quickly. And I can help them not get frustrated super quickly. I think engagement is everything, not just in terms of attendance, but in terms of how much people are willing to get vulnerable and be open and do the work. And there's a lot of vulnerability and stabilization. So the other thing I want to just kind of highlight here is talking in detail about vivid events or vivid details about the events. That's not the only way to have serious vulnerability. Just sitting in a room with you and letting you know that they're having a really bad day for a lot of these folks is incredibly vulnerable. And I really want to kind of stress the importance of particularly depending on your trauma profile, like validating the heck out of that and letting people know that this is trauma treatment. Like what we're doing right now is helping you communicate, track, manage what's going on in your life. So I think there's a lot of ways in which that engagement and that relationship can really carry people through and reduce the amount of I'm broken, I'm a failure, I couldn't even be successful in PTSD treatment. I also like the idea of the emphasis on integration and intimacy. The idea that we're more than just trying to, that what we're shooting for is more than just a reduction of symptoms. We're really trying to help people reconnect with wanting to be alive, wanting to be part of humanity, wanting to feel good about who they are and feel like there are at least some people out there that are worth getting to know. And that's not always going to be captured in a PCI. So I think it's really important to think about what motivates people, what drives them, what gets them excited. And for so many of our folks who have a history of substance use disorder are still struggling with it. Man, the idea of joy without a substance is just a foreign concept. So I don't say this lightly. I think this is such an incredible goal to get to, but when you get it, I think, for me, it's one of the greatest gifts of what we do is getting to see somebody actually reach that point where something brings them joy that's not a substance and they feel like they deserve it. I think that's a very hard end point, but one worth fighting hard to work towards. So I'm aware of time and it's 347. So I can pause here and have more questions and answers. There's additional slides here that talk a lot more about group psychotherapy. So you're welcome to kind of look through those and reach out with questions. I guess all I would say is everything I just described, you got to think about that, but with multiple people at the same time when you're working with them in a group, especially with trauma survivors. So you're really starting to look at how do you scaffold expectations? How do you communicate what you're asking of people in lifetime with multiple people all at once? So that's kind of the trick of group psychotherapy. I'll pause for questions or comments or reflections. Yeah. Well, I have one, so I'll throw it out there. So you were mentioning, we couldn't really get to group, but you're doing group with a lot of people taking all these considerations into play. So with 12-step, being a peer-run, spirituality-based model, just focusing on the substance use, I knew there can be a lot of difficulty or a lot of complications for people that have had trauma or PTSD. I'm wondering if you have any advice or ways that you discuss either before they've gone to a meeting or difficulties they had, any advice for people, especially with the complex or the developmental trauma. Yeah. You're just going to make me push forward to a slide. That's what's going to happen there. So this one, if I had to pick one slide to review for groups, I'd say these are the biggest challenges of working with trauma survivors in group settings. I would include AA, 12-step community with that. And a lot of that would be relationships outside of the group. So it's kind of, how do you manage boundaries? How do you manage asserting yourself? And so I think what I usually do is I ask them to go really, really slowly. So the goal is to actually get them to try, and that's a huge step. So when they have trauma, they're avoidant. So if you look at engagement, are they really, is it a warranted fear? What do they think is going to happen? So I'm going to explore with them what happens when you walk into a meeting and we get to kind of test that out. And if it feels like a trauma-based worry that we can kind of safely test together, we're going to have them go ahead and do it. Well, I think they're going to, actually there's a cartoon that seems appropriate, that one. If I actually tell people what's really going on with me, like they're not, they're going to be horrified. Like what I have to share is so overwhelming and so awful that they couldn't handle it. That's often the fear. And I think what's so powerful about 12-step communities is that usually that's not their experience, right? But what we want to come back to is you start with, can you expose them? Can you get them a little bit engaged? But then I will usually say, like before you ask for a sponsor, before you take numbers, before you do anything, the first meeting I just want you to observe and come back and report. If I'm really worried about their ability to kind of find healthy people, I want to go slow and I want like a lot of feedback if they're willing to do that with me. What did you notice? What did you think? And I think you want to say really kind of honestly, like a lot of people that you're going to meet there could be really great sources of support and recognize that they're going through their own challenges. So they may struggle to know kind of what's an appropriate thing to ask of you, how they're going to be a friend to you. So I think it's really important that we talk about kind of what you discover as you're trying to connect with people in these communities. This is why the concurrent model is tricky because I'm having to guess what's going on in 12-step meetings versus if it's a group I'm running or a group my colleague is running, I get to manage it in lifetime where I get to actually look at what's happening as they develop in group and kind of work with it. Because more often than not, not more often than not, oftentimes there's problems with developing relationships outside of group that can lead to, you know, there's a falling out, there's a violation, there's a boundary violation, and then they don't want to talk about it in group, they stop coming to group and then they don't get the treatment that they need for their own healing, right? So in your own clinic, you can kind of deal with both parties at the same time, whether it's individually with each in the office or actually live in the group. But with 12-step, it's more of like observe, come back, report, and you're gonna be listening for ways that they might be ignoring red flags, they might be jumping to conclusions, all of that kind of stuff. So you're gonna be a much more active partner in trying to help them assess safety. Does that answer your question? It was a long response. Yeah. Okay, good. So just looking at this slide, you know, I think there's so much benefit to working with folks who have trauma and addiction in a group setting. I don't know about you guys, but I find very few people are super eager and want to do that from the get-go. The request for treatment is almost always individual. I don't know if people have different experiences. There's a lot of reasons to fear. Going into group, I'll actually go back to another slide for this. I think there's a lot of fear of rejection and alienation, but also with the folks who experience maybe kind of negative views of self, they don't trust themselves. They don't feel competent around other people. So they don't want to be put in a situation where they might blow up and then feel bad about themselves, or they just don't particularly, I just had this yesterday, they don't see the value in other people's perspective or opinions, right? And as much as you don't want to necessarily bring somebody into a group who's like, you guys don't have anything to offer me, there's nothing you could tell me that's relevant, that's probably somebody who needs to be in a group at some point, because they're missing a really rich resource by actually listening to other people's feedback about how they're being perceived. So I always want to talk to people about their concerns about group, and I may keep certain people out. So if somebody is particularly hostile, or I think kind of leans towards potentially abusive, what if we would not put them in a group? I think if somebody pulls for a lot of inappropriate kind of boundary violations, like seeks out a lot of caregiving in a way that's not great, we might be concerned about putting them in a group, and we might pick a much more structured group, if that makes sense. And you're working individually to get them to a place where they can join a group setting. Because if you can get them into a group, and if they're relatively appropriate for group, the benefits can be incredible. You're exposing them to being around other people. Just that, being in the same room with people who maybe have experienced similar things can reduce their sense of shame or alienation. Understanding your impact on other people is tremendous, and actually seeing people just share information can be incredibly valuable. So big proponent of groups that can be really helpful. I think the one thing you really got to look for when we're thinking about trauma profiles and base-based models is you got to stay flexible. So if you're seeing a problem in group, if people are fighting and it can't be managed, like there's just a high level of kind of bullying or inappropriate behavior, you've got to be able to be really clear on how do you establish kind of expectations and norms and rules about what is and isn't appropriate. And that keeps not just the other members safe, but that keeps the individual who can't regulate safe. So there's just a lot of management and safety. And you're always looking out for enactments. So with interpersonal trauma, you're always going to want to look out for ways in which, you know, the group kind of identifies a scapegoat or identifies patterns where it may recreate kind of the traumatic experience that they've had before in their life. So you always want to try to catch that and cut it off at its past. But if you can get people to fully engage, be vulnerable, challenge their beliefs about kind of who they are, it can be unbelievably powerful and meaningful. Five minutes. Final thoughts, feelings, musings. I'll leave you with this last slide, just that I'd encourage you anytime you're thinking about trauma therapy with anybody, I'm always looking for both the kind of a reduction in actual symptoms, an increase in reported quality of life, but you also want to look at, you know, how are they as a person? How does it feel sitting in the room with you? Does it feel like they have more flexibility and more ability to communicate and that they can kind of more quickly recover from one emotion to the next? If ever possible, what do their loved ones say about how they're doing and how they've been changing? I think those are really important treatment outcomes that aren't always captured and reported in studies, but I think are really valuable. Any specific, very good question for extra individual training for us as providers. Oh yes, Trauma and Recovery by Judith Herman. I think it's 92, it's 92 or 93, but I'm gonna put it in the chapter. Judith Herman's Trauma and Recovery. Yeah, I would say in terms of additional individual training if you can find, I mean, there's sometimes systems and programs that offer like very formalized. Training in a trauma-focused protocol, if you have access to that, I would say do it. Even if you can't get protected time to see a bunch of clients using it, get the training because it's gonna be really helpful in working with people. And if you can get to do it, I really encourage you to do it. If you don't have access to that, but you have access to colleagues who are trained more than you in trauma and they're running a group or they're open to consultation, lunches, coffee breaks, set those up and just talk and ask questions and try to take advantage of the expertise of people who have more training in a certain areas. Especially, I mean, I regularly reach out to a couple of my colleagues here who have incredible experience in training in race-based trauma and I make it a point to routinely kind of consult with them about a few of the cases I'm working with. So I think that's helpful too. Well, we're pretty much at the hour. So if less people have any burning questions, I wanna thank you very much, Dr. Berkman for this wonderful lecture. I feel smarter for having attended. And I think that I've taken away multiple pearls that I can use with patient care right away. So thank you again. And let's just remind ourselves next month. It was a nice segue. We have integrated group therapy with Dr. Roger Weiss from Harvard, which will be a great addition to this lecture. And thank you everybody for joining, for your attention. Thank you, everybody.

trauma psychotherapy

trauma profiles

tailoring interventions

complex trauma

developmental trauma

neglect and child development

race-based stress

moral injury

integration and trauma

evidence-based psychotherapies

substance use and trauma

stabilization and coping skills