Healing PTSD with TEAM CBT

Healing PTSD With TEAM CBT
 

Jill Levitt: Good morning and welcome everyone to our webinar on healing PTSD with Team CBT, which will be given by Daniel Mintie from the Feeling Good Institute.

My name is Jill Levitt and I'm a clinical psychologist and I'm also the director of training with the Feeling Good Institute. And before we begin the webinar today, I'm just going to let you know a few procedural items. If you notice, you have a GoToWebinar control panel on the right side of your screen. And about halfway down, you'll see a caret that says questions. If you click on that caret, you can enter questions and we encourage you to enter them throughout the broadcast. Just type in your question and hit enter and Daniel will be able to see your question.

And then during the last 10 minutes of the presentation today, Daniel will turn to the questions. I also want to let you know at the very bottom of the control panel, you have access to the presentation. So if you'd like to download a copy of the presentation, even print it out and look at it as we're going along or keep it afterwards, you're welcome to do that. And that's at the bottom of your screen where it says handouts. And the last thing to let you all know is that if you're attending and hoping to receive continuing education credit, you do need to stay for the entire presentation. So GoToWebinar takes attendance and we have access to that and we're only permitted to give people continuing education credit if you're present for the entire presentation for 50 minutes or more.

So please make sure that you stay through the questions until we end the broadcast. And the last thing I'll let you know is because many people ask questions about continuing education, how that works. You will receive an email from Feeling Good Institute with a survey within about 24 hours of this presentation. You'll need to complete the survey and then you're automatically emailed a certificate of completion. So let's see. Now that we have that out of the way, let me tell you a little bit about what is Feeling Good Institute and then I'll introduce Daniel to you. So I'm just waiting until I see the next slide. Here we go. So Daniel and I are both from Feeling Good Institute.

I had mentioned that I'm the director of training and Daniel is one of our amazing online instructors through Feeling Good Institute. So we're an organization that's dedicated to better therapy. That's the way we say it. We create systems that support, guide, and inspire therapists to provide effective therapy for their patients. We provide online training as well as in-person training for therapists and advanced cognitive behavioral therapy tools and techniques, which are based on the work of Dr. David Burns. We also have a certification program where we certify therapists and TEAM-CBT so that we can help to support therapists in their training and recognize quality therapists. And finally, we're a treatment center. So we actually have treatment centers in Mountain View, in New York City, and in Tel Aviv, Israel. And we're also excited to be able to provide teletherapy.

Someone is saying they can't hear me. Can I just ask real quick, can someone enter in their text box that they can hear me so that I know that's just an individual problem? Okay. I just got a whole lot of I can hear. So if you can't hear me, unfortunately, it might be a technical problem on your end that you'll need to look into, but I'm glad the rest of you can hear and see me. Okay. And so now let me just introduce you to Daniel Mintie and he'll be providing the rest of the more interesting aspects of the webinar today.

So Daniel is a trainer at Feeling Good Institute. He teaches TEAM-CBT at universities and training centers worldwide. And he's just come out with a new amazing book that's called Reclaiming Life After Trauma. It was published this summer by Inner Traditions Press. And I'm so pleased that Daniel's with us today to share with you some gems from his work with trauma survivors on his new book. Thanks, Daniel.

Daniel Mintie: Thank you, Jill. I so appreciate all the time you've put into setting this webinar up for us this morning. And thanks to each of you who's joining us, either live or downstream with our recording. Appreciate your taking this time out of your busy schedules. Today we'll be looking together at one of my favorite topics, which is trauma recovery. We'll begin with an overview of post-traumatic suffering through time, and then move on to looking at ways in which TEAM-CBT can help patients who are suffering in this dimension.

We'll then review some recent science on the physiology of trauma and on how CBT and other treatment modalities can reset PTSD-related structural and functional changes in the body and in the brain. So post-traumatic suffering is as old as the human record. Post-war suffering in a Mesopotamian population is detailed on a tablet dating back 3,000 years.

Civilians there experienced panic and despair and insomnia, which are precisely the symptoms we see today in populations in Gaza or Kosovo or in New York City after the attacks there 17 years ago this morning. On the military side, the Greek playwright Sophocles was himself an army general. His play Ajax presents the suffering and suicide of its eponymous hero, a textbook PTSD veteran.

World War I produced the term shell shock. It was believed the psychological distress of infantrymen was caused by the concussive force of artillery shells. World War II gave us a new term, battle fatigue, which reflected a change in diagnostic thinking. The length of the campaigns in that war were now believed to be the source of psychological symptoms. The term PTSD first appeared in DSM-III in the aftermath of the Vietnam War. In each edition of DSM since then, the diagnostic criteria has continued to change, reflecting the ongoing evolution of our diagnostic thinking.

In his wonderful book, Caring for Patients, Allen B. Barbour differentiates two paths for diagnoses. The first would be disease, which Barber sees as characterized by pathology, a circumscribed entity identified by predefined objective criteria. An example would be Ebola. If the Ebola virus is identified in a patient, this would provide the foundation for the diagnoses of Ebola virus disease. PTSD, on the other hand, would be an illness. That is this subjective experience of feeling physically and emotionally unwell. It's important to note that suffering in both cases is real and measurable, and what brings patients to us for treatment. I find it helpful to conceptualize PTSD as both an illness and a solution. Chapter four of our book is titled The Hidden Wisdom of Symptoms.

It owes a debt of gratitude to Dr. Burns' insight into the motivational factors that underline illness. I see PTSD symptoms not as expressions of psychopathology, a term that shifts our perception towards disease states, but rather as good faith, though maladaptive attempts to resolve some life problem. Feeling detached or estranged from others is one diagnostic criteria for PTSD.

I've worked with more than one veteran who, after leaving the military, chose to live alone in the woods, sometimes for years. In part, this was a successful strategy to protect others from the veterans' lethal outbursts. These human beings had experienced all the violence they cared to experience in one lifetime. Protecting life had become a deep core value, and living outside the human community was an expression of this fact. I've noticed that very often the very best people seem the most vulnerable to PTSD. A soldier who's mostly self-referenced could see death all around and just be glad he or she were still alive.

It's the big-hearted among us, the most sensitive and empathetic, who seem the hardest hit by PTSD. DSM breaks out symptom clusters into four discrete areas. First is avoidance, and this could be avoidance of memories or emotions associated with the trauma. It could also be avoidance of external triggers, places, sights, smells, sounds that might reactivate that traumatic content. The second is negative emotion or negative self-image. The third is re-experiencing, and this could include nightmares or flashbacks. And the fourth is the so-called fight-or-flight response, this over-activation of the sympathetic nervous system. We'll be looking at treatment issues that arise in each of these sectors and team methods we can offer patients to address them. Before we do, let's get better acquainted by running our first poll. Jill, can you bring that up for us?

Jill Levitt: Yes. So you should see on your screen now a quick poll, and we'd like you to answer the poll. It asks you how much of your practice consists of trauma survivors so that Daniel can get a feel for the audience. So we're just going to give you, you know, 30 seconds now to answer that question. Is it none? About a quarter of your practice? About 50 percent of your practice? About three quarters of your practice? Or 100 percent of your practice? And in just a moment, I'll close the poll and then we'll share the results with everyone. Okay, if you haven't indicated an answer yet, go ahead and do it now. Okay, I'm gonna close the poll and then I'm gonna share the results with everyone. Daniel, can you see the results on your screen?

Daniel Mintie: Not yet. Let me see if I can change my windows here.

Jill Levitt: You guys, I'll read them to you now then. Does that sound good?

Daniel Mintie: I'd appreciate that. Yeah, thanks, Jill.

Jill Levitt: You all should be able to see the poll results which I've shared with you. So about 12 percent of our participants have none of their practice devoted to trauma survivors. 41 percent say that 25, a quarter of their practice is trauma survivors. You've got 26 percent of the audience is saying about half of their practice is devoted to trauma. And then you have 15 percent who are saying three quarters of their practice is focused on trauma. And five percent of the audience has 100 percent, so the entire practice is devoted to trauma survivors.

Jill Levitt: Wow.

Jill Levitt: Now I'll put you on the screen.

Daniel Mintie: Yeah, thanks, Jill, and thanks for letting us know how this breaks out in your own clinical work. It's wonderful that we have a whole range here, people who just dip into this occasionally, and some of our colleagues, perhaps with the VA, who are just doing this hour after hour. One of the weaknesses of the webinar format is that I don't get the opportunity to learn from you. And a bit later in our webinar, we'll be talking about some other training venues that we could see and talk to each other about our work.

And when I do that with my classes, I learn at least as much as they do. We put all of our IQ points together, and we're much better than we are on our own. I'd like to talk for a moment about team. Many of you are quite familiar with the team model. Some of you are not. And TEAM-CBT is one of many gifts that Dr. Burns has given the world. Our global Feeling Good Institute family is certainly another. I know there are folks with us probably from all of the continents here this morning, except Antarctica. I think I got Antarctica as a continent. I don't think we have any colleagues there just yet. TEAM is an acronym and stands for Testing, Empathy, Agenda Setting, and Methods. The testing portion relates to measurement, which we see as a critical ingredient to doing good clinical work.

Empathy is our therapeutic alliance with our patients. And we see that this is also non-negotiable. Agenda setting is oftentimes what makes or breaks our therapy. In the training and consultation I do, when therapy is getting off track, I'd say 90, 95% of the time it's an agenda setting issue. And we'll be looking closely at agenda setting issues that come up in trauma treatment here this morning. And then finally, there is our methods section, which includes at least 50, probably closer to 100 different TEAM CBT methods that we can offer patients who are experiencing trauma symptoms or other forms of emotional distress.

I think of the 14 quadrants less as a linear sequence that we would click through and more as dimensions that are always present in any moment of our work. So in this way, TEAM is a fractal. Each part contains and expresses the other parts. So accurate testing sharpens our empathic connection with patients. And sometimes empathy itself is the only method that a patient needs. When it comes to treating trauma, some special considerations arise in measurements, both in diagnosing PTSD and in treating it.

I use Dr. Burns easy diagnostic system with most all of my patients. In my trauma work, I also use scales like the PTSD checklist or the clinician administered PTSD scale. The value of these instruments lies in the fact that they cover a lot of diagnostic territory. They're also indispensable when we're doing research. One danger of such scales is that they focus us on symptoms, not on the human being experiencing the symptoms and very likely experiencing other forms of distress. So these questionnaires can set us up to miss the forest for the trees.

That is to miss seeing the way in which the illness is also a solution, allowing patients time to discuss their concerns with us at length and their own words before asking any questions at all can protect us from subtly leading the witness to produce an account of suffering that fits our preconceptions and treatment strategies. Early in treatment, a patient might become quite dissociated without our realizing that. So I found that in session measurement of dissociation can help us know when that's happening and also pinpoint the trigger.

I use a zero to ten scale and check in with patients when I have a question about depersonalization, say, or derealization, these common forms of PTSD dissociation. And I also invite patients to share their dissociation number with me at any time. Sometimes they'll just do that visually and we know what it means, six to ten. Also early in treatment, patients are sometimes unaware of a particular emotion, except as a physical sensation. The body has become the theater for the patient's emotional life and emotional suffering. It registers as psychogenic pain.

Asking about the frequency and intensity of physical sensation can help identify when an emotion is being converted to a physical experience and provide a doorway into the emotion itself. Moving on to the empathy portion of the team model, we consider that our empathic connection with patients is the very ground from which our work arises. It's certainly also one of the very deep pleasures of the work that we do.

And particular issues come up in our therapeutic alliance with trauma patients. We use measurement of positive and negative emotion to guide our work, but trauma patients might be far removed from their emotions, making such measurement problematic. We team therapists use a brief scale called the evaluation of therapy session or ETS to get patients post-session feedback on our work.

A woman with a long history of sexual trauma once marked not at all for the item, my therapist understood what I was feeling inside. When I processed this answer with her, she explained, I didn't have a clue what I was feeling inside. So I figured you wouldn't either. And of course she was absolutely right. Many trauma patients have strict rules against experiencing and expressing negative emotion. They may have learned in their families of origin that expressions of fear or anger say, traveled with real physical danger. These patients might minimize any negative feelings, particularly towards a therapist and over-report positive emotion. Our own feelings can sometimes be a doorway to moving the work forward and expressing them might require the same courage we ask our patients to bring to the work. I was treating a patient we'll call Sarah, who was a young woman who had experienced a vicious sexual assault.

In an early session, Sarah was talking about a conflict she'd experienced with a friend that week. As I listened, I felt my discomfort growing. I was feeling something and telling myself I shouldn't be feeling that. I finally screwed up my courage and asked Sarah if I could share something with her. When she agreed, I said, Sarah, you have a wonderful heart, a brilliant mind, and are talking about something that's quite important to you. So I'm confused as to why I'm, as I'm listening to you, I'm feeling somewhat bored. I wonder what you're feeling as we sit together this morning. Oh my God, Sarah said and burst into tears. And at this point, my anxiety went through the rough until she continued, me too.

Thank you for saying so. Nobody has ever done this before. They just let me go on and on. And I think they're secretly glad, but when they can finally get away, we moved on to working with a team tool called the interpersonal downward arrow. And Sarah realized how her strict rules against experiencing and expressing negative emotion had separated her from others for quite some time and separated her, of course, first of all, from herself, from her own heart. So her bright, chatty presentation was a form of what I call camouflaging, hiding who she really was from others and perhaps from herself.

Camouflaging comes up regularly in trauma treatment. Another patient would break into a broad smile whenever she felt angry. This too confused me. And by sharing my confusion, we were, as with Sarah, able to find a new way forward. Let's move on to the agenda setting portion of the TEAM model. As PTSD is both an illness and a solution, we can start setting a treatment agenda by paradoxically siding with the status quo.

We can consider together the many upsides of any PTSD symptom. Doing so helps patients feel greater compassion for themselves to understand and accept themselves more and removes that self-rejection, which perhaps is the greatest barrier to change. It also casts the patient, not the therapist, in the role of arguing for any new, more adaptive solutions.

In treating trauma, a paradoxical approach also helps us avoid a common pitfall, which is recapitulating an abusive interpersonal dynamic. I treated a young man, let's call him Sam, who had experienced extensive abuse in his family of origin. Sam was very bright, very friendly, and gave me tremendously positive feedback on our work. Whatever I gave him seemed to work magnificently. His after-session symptom scores would all be way down or be at zero, and his ETS was just over the top, happy with me and with our connection. But at the start of our next session, his symptom scores would be pretty much right back up where they'd always been, quite high.

You probably understand me well enough by now to know I smelled a rat in our little garden of Eden. Sam and I worked through an interpersonal downward arrow and surfaced a core rule that he had for relationship. I will become your slave, and thus I will control you. By giving his abusers whatever they wanted, young Sam retained a semblance of control in a chaotic and threatening home. As an adult, he continued doing business this way, and while liked by many people, he felt increasingly depressed, worthless, and alone. I then asked Sam if this had been his rule for our relationship, and immediately he said, oh, yes.

He'd been playing the role of the good patient, giving me answers he thought I wanted to hear. In this session, he accepted my invitation to open up to me in a more authentic way. My favorite line from the second half of that session was, Daniel, I want to tear you limb from limb.

Well, of course he did. Me and everyone else who'd ever accepted his invitation into this form of pseudo-relationship. Except for helpfulness, which was believably off the charts on the ETS after that session, the rest of my marks were considerably less sunny than I'd ever seen. Sam and I both considered this a crowning success, and it was a turning point in his before-session scores to start going down and staying down week over week. You'll notice that we're about halfway through our time together here this morning, and we're only now getting to methods. If you're a Teamster, this will make a lot of sense to you.

If not, it might be somewhat perplexing. You signed on today to maybe learn some new ways of helping people. TEAM distinguishes itself from other forms of training. And TEAM distinguishes itself from other forms of trauma care by putting methods at the bottom of the model. Other schools might offer methods right out of the gate, EMDR, say, or prolonged exposure. Yet until we pass through these other dimensions of the TEAM fractal, I'd be somewhat pessimistic that even the most outstanding method would help the patient.

But once we've done good testing, secured a therapeutic alliance, as I was finally able to do with Sam, with Sarah, and agreed on an agenda, the stage is now set for what can and is rapid and dramatic and lasting recovery. When avoidance is in the picture, exposure is non-negotiable. Cognitive exposure would be, say, imaginal, revisiting an event or situation from the past. Sometimes the war itself or the person who attacked me is no longer accessible. But we can imaginatively recreate that situation that the patient has been avoiding and begin to desensitize themselves to those triggers. We also like to bring in creative engagement as a method for avoidance.

I was treating a woman who had experienced a physical assault and stopped working. She's a painter, stopped painting, and became quite symptomatic. So when we first met, it became clear that she was putting a lot of energy into avoiding thinking about what had happened, her feelings about what had happened, her fears about what that meant about her and relationships that she was in. So all of this energy that could have been going into painting was going in this other direction. She was feeling very stuck and alone and unhappy. So what I suggested that she do was to create a canvas that would express that trauma.

And when I suggested this, she immediately lit up. She really liked that idea. And when she came back in, I think it was about two weeks later, she had this canvas rolled up under her arm and she unrolled it and it just took my breath away to see the emotional meaning of the events. She had described the events to me, so I knew what they were. But to see what they meant to her and meant to her heart brought tears to my eyes. And it was a wonderful moment of her reconnecting with herself, not avoiding any part of herself, including this horrific event, and also reconnecting with her creative impulse.

She started painting again. And soon thereafter, our work together was done. We can also, of course, do in vivo exposure. I was treating a person who'd been caught in a crossfire of a gang fight in a big city downtown. Terrifying experience, the glass getting shot out of his windows and him on the floor wondering if people coming by with guns were going to kill him or not. And so he started avoiding going downtown at night, and then he started avoiding going downtown, and then started avoiding going outside in his suburban neighborhood, except to drive to work.

And then finally, the drive to work became very, very frightening, as did answering the phone, any kind of contact with the outside world. So what we agreed was that he would begin an incremental exposure program, where initially he would agree to pick up the phone and to go outside a number of times a day, walk around the block, to go to work, and eventually start reclaiming the territory that he had lost to his PTSD. Another way that I've done that with patients is to do flooding.

I had a woman who had survived a devastating motor vehicle accident and was terrified of driving, particularly on interstates where the accident had occurred. So she needed to drive on the interstate though, because that's her job required that she travels around a lot here in New Mexico. And so what she agreed to do was to gas up her car, take her credit card, and go drive on the interstate from city to city, hour after hour, until one of two things happened. Either it was time to come home and go to bed, or she was no longer fearful of being on the interstate, having big rigs go by, which had been the situation for the accident. This negative self-image is a very common sequelae of trauma. And from a TEAM perspective, we find double standard approaches can be very helpful.

And we think that's true because it taps into that deep empathy that so many PTSD patients have. They can extend that to others, and our double standard tools allow that to extend that to themselves. We can also positively reframe that negative self-image, that negative self-talk.

This is a doubly paradoxical approach. It focuses on the solution aspect of the illness and looks at all of the awesome things that feeling crummy about ourselves say about us. It can be very, very powerful for some patients, some of the time. None of the tools that we use help all patients all of the time, and that's why we've created as many of these as we have. And because PTSD is just one of a handful of DSM diagnoses that requires an event from the past, memory re-scripting can be very helpful. I sometimes use hypnosis to do this and can use hypnosis to help rewrite traumatic memory or to actually install missing memory.

So I had a patient who was very sad, not only about having been abused as a child, but equally about not having positive memories of things like Christmas or birthdays. At her request, I installed these memories in her subconscious mind, and while she had amnesia for those memories consciously, her PTSD symptoms went down and eventually in conjunction with the other work that we did went away. We have a suite of interpersonal team tools that we use for relational conflict.

And what I found myself experimenting with is using these tools in an intrapersonal direction. So downstream from an abusive trauma of some sort, an abusive relationship with parts of ourselves can emerge. And this seems particularly to happen if the abuse happened early in life. And so this recapitulation of our relationship with parts of ourselves might have to do with some part of our own body. I had one patient who had been raped and told me, I love myself from the navel up, but I'm done with everything else. Or it could be related to feelings or other aspects of who we are.

So just as we would do an interpersonal downward arrow, which Sam and I use to help see what's going on between us, we could do an intrapersonal downward arrow that would look at what's going on in these relationships of different parts of myself, my body and my mind, the top of my body, the bottom of my body, my emotional life, my cognitive life. What are the roles here? What do these different parts do? And then what are the rules that are driving those roles? And this can be tremendously revelatory for patients and for ourselves, and also set the stage for understanding what's happening interpersonally, because those intrapersonal dynamics are very likely to get projected into our relational lives. And then we'll experience the same dynamics there.

Another interpersonal team approach is the five secrets of effective communication. We teach this in our training group, so I teach this to many of my patients, and it can be tremendously helpful in terms of resolving interpersonal conflict, reconnecting with each other in human and authentic ways. So one of my patients started doing this with himself, and he'd say, so Daniel, you're telling yourself that after all of that bad stuff that happened to you, you're just no good, and you know it, and everyone knows it, and you sound really sad and really hopeless.

And I noticed as I was listening to you, I too felt such sadness, but also I was really glad, you know, we're talking about this. You're a great guy, actually, and I'd love to hear everything you'd have to say to me about your hopelessness and pessimism and loneliness. He found this tremendously helpful, and so I've started offering it to other patients. I've started experimenting it with myself as well if I get upset. Oh, Daniel, you're feeling nervous about that webinar you're going to be doing, and it helps me reset my relationship to those parts of myself. Another approach that we use in the interpersonal domain, but which I have offered to patients interpersonally, would be smile and hello practice, but instead of doing that with someone out there, doing it in a mirror.

I had a patient who experienced extensive sexual trauma for most of her childhood, and her abuser told her that she was a hideous little girl, and so she just accepted that this was the case. And she's now a middle-aged person. When she looked in a mirror, she wouldn't see herself. She would see that cognition, oh, that's hideous, and would immediately turn away, had a very hard time looking into mirrors, looking into her own eyes. So she agreed to start doing smile and hello in the morning in the mirror and told me that she found that kind of sea change for her in terms of her relationship to her physical appearance. In our book, we share a tool we call the Dream Decoder, which our friends at the Young Institute in Zurich gave us, which is a kind of high-speed Jungian analysis tool for dreams.

And a number of our patients who have been troubled with recurrent nightmares have found that very helpful to unpack what's the meaning that's underneath the surface of these scary dreams. We'll also invite patients to physically reenact the content of the nightmare, and we find that bringing the body into that content seems to reset the relationship to it, and in particular, seems to have effects in the hippocampus. So instead of experiencing the content passively, to actually experience it actively seems to be very helpful for some nightmare patients.

We do something rather similar with flashbacks, that we can enact them. Instead of experiencing them cognitively, emotionally, we can re-experience them behaviorally, and we'll do that with a twist, which is we can rewrite the content in any direction that we want as we go along, and doing so resets our experience from being the victim of something to actually being the agent of something. And the fighters I work with particularly like and understand this shift from being the prey that something comes and gets to being the hunter, one who's going out and looking for that, and rewriting that physically in a way that oftentimes seems to put an end to flashbacks.

When it comes to the fight or flight side of things, many of our patients ask us for help with physical tension and psychogenic pain, insomnia, that kind of thing, and one or more of these physical symptoms are just about always present when we're looking at a diagnosis of PTSD. So we're going to take a moment and conduct our second poll, and then move on to look at some physical expressions of PTSD and some of the science around that.

Jill Levitt: Okay, so you should be able to hear me again, and I'm just launching our next poll, which is to ask our audience members, do you offer your patients methods to address physiologic trauma symptoms? And we're just asking you here in this case, if you're a practicing therapist, do you offer your patients these methods, yes or no? And we'll wait for a minute just to get as many people to answer the poll as possible.

So almost everyone has voted. If you haven't yet, go ahead and enter your answer, and then I'll close the poll and share the results with everyone. Okay, so it looks like 70% of the audience said yes, you do offer patients methods to address physiologic trauma symptoms, and 30% of the audience said no, you don't.

Daniel Mintie: Okay, well, thanks, Jill, and thanks, folks, for letting us know. I'm so heartened to hear that 70% of you are offering patients methods that they can use to address the physical side of things. And for the 30% who aren't currently doing that, if you'd like to begin doing that, there's some tremendous resources out there, including our book.

My co-author, Julie Staples, and I wanted to take an integrative approach to self-help for trauma. And in our book, the physical approach we use is kundalini yoga. We offer this as well at integrative trauma retreat that we offer here in Dallas twice a year.

Next event will be happening next month, where we use a protocol of TEAM CBT and kundalini yoga to address participants' physical and emotional responses to trauma. On the TEAM side of things, there are tools that I've found very helpful when it comes to fight or flight. One is just self-monitoring to have a way that the patient can both experience a physical symptom and count it, and then at the end of the day, just write that number down so that we can see day over day how often that's happening.

And in addition to being testing, this can also be a method. Self-monitoring can sometimes reduce the incidence or the intensity of these kinds of physical experiences. Another thing that I prescribe is negative practice, where again, we would actually go out and look for the physical symptom, recreate it for some period of time, beginning and end, and then dose ourselves with that, and thus reset our relationship to it from being the victim of it, being the prey, to being the hunter, being the one going out and looking for it.

We can also bring in some of our motivational tools, the cost-benefit analyses, and look in a cognitive way at the upside of experiencing an exaggerated startle response, say, or hypervigilance of some kind. We can also bring in what we call the acceptance paradox of instead of responding to tension with tension, to learning to accept that our bodies, as they work through this process of trauma recovery, will be doing all kinds of things and learning to be okay with that, as opposed to seeing that as one more problem that I need to solve. There's a wide range of body-based interventions out there.

Ours is Kundalini Yoga, but many, many others, and perhaps some of you have had great success utilizing some of those as well. Let's look at some of the somatic issues here. Bad news is that PTSD changes things, and it changes both structure and function throughout the brain and body. It's these changes that often seem co-equal with the cognitive and emotional changes we've been discussing in producing patients' experience of being unwell. The good news is that CBT and other modalities have been shown to reverse these structural and functional changes, restoring physical wellness down to the molecular level. Our language will separate body from mind, but in reality, these aren't separate things.

We necessarily think thoughts and feel feelings with our entire physical structure. If we're going to feel an emotion like anger, say, or fear, that activity in the amygdala has correlates throughout the entire body. Respiration changes, there are cardiac changes, muscle tonus, endocrine changes, and that makes a kind of sense to us. Sometimes we do fall into this Cartesian separation when it comes to thinking. You think, well, we might feel with our whole body, but we don't need our stomachs to think. But there is all kinds of new data that says actually we do, and things like temperature affect thoughts.

If we hand people a warm cup of tea and they meet someone, they'll judge that person as being more trustworthy than if we hand them some iced tea and they meet the same person. When we think about the future, we lean forward a bit. When we think about the past, we incline backwards. There are many studies related to the somatic nervous system, states of tension or relaxation and thought patterns, gravitational effects, and many other physical phenomena. At the level of genes, we've seen that FKBP5, one of the genes that helps moderate stress response, is reduced in folks who meet the diagnosis for PTSD. Then we found that if we dose them with CBT, that gene expression actually goes back up.

The amygdala, the seat of our emotional processing, is overactive in PTSD. We see that CBT and mindfulness-based practices reduce that overactivity. Hippocampus, the structure implicated with memory, which we've seen is a big issue with PTSD. PTSD patients have reduced hippocampal size. CBT, mindfulness practice, and yoga increase hippocampal volume. That increase correlates with improvements in memory. The ACC is important at regulating the stress response. And its size and activity is decreased with PTSD. CBT and mindfulness practice increase ACC volume and function. Those increases are measured with symptom reduction. Heart rate variability is another measure. Higher variability between heart rates is correlated with parasympathetic activity with rest and digest.

With PTSD, the heart's less like a human thing beating in the breast, more like a metronome, bang, bang, bang. We see that CBT and yoga raise HRV to levels of healthy controls. Immune function is a newer area of study. PTSD is comorbid with all kinds of illnesses. And CBT and yoga have both been shown to regulate genes that are associated with the inflammatory response. So why would CBT and these physical things produce the same effects? We don't know yet, but we're thinking there are probably some as yet unrecognized mechanisms underneath CBT or yoga that would be common.

And it's an exciting area of research for us and our colleagues. If you would like to dip into a bit more of the work that we're doing here at the Feeling Good Institute, we'd love to have you join us. I teach an online class every other Friday from 12 to 1:45 Pacific time. It's an opportunity to both receive some didactic training and to receive case consultation on trauma or anxiety, depression, interpersonal conflict, whatever it is that you're treating. And if you'd like some additional information about our work, you can visit our website, Reclaiming Life After Trauma. In there, you can download a free chapter of our book and also learn more about our upcoming integrative trauma recovery retreat, our next one being run the end of next month here in Dallas. And if you know someone who might be interested in either of those resources, we very much appreciate your passing these links along. All right.

Jill Levitt: I'm going to interrupt you for one second, Daniel.

And before you turn to questions, I know you only have a few minutes, but I noticed that one of our learning objectives was worded slightly differently than the language you used. I wondered if you could share with people. One of the learning objectives says name two biomarkers of PTSD. And I just noticed you didn't use that vocabulary, although you talked about this. Would you be willing to just word that for us? And then we can maybe answer a question or two.

Daniel Mintie: So the inflammation that we're talking about and the gene expression would be an example of one biomarker for that disease, as would heart rate variability. So as heart rate variability decreases, PTSD symptoms go up. And likewise, these structures in the brain and the decrease in or increase in size in those structures. We're also seeing that there are changes in the gut biome that are correlated with PTSD diagnoses. And some of our colleagues are looking at pre and probiotics as adjunct PTSD therapies to help reset the downstairs brain, which we now understand talks all of the time with the upstairs brain. So these would be some examples of biomarkers for PTSD and how our work reset them.

Q&A Session