Video 4: When Emotional Engagement is Impaired: Avoidance.
In the next few videos, we’ll talk about factors that can
impair effective emotional
engagement and exposure.
We’ll talk about avoidance, then under-engagement, then
over-engagement.
Addressing avoidance is so important.
Validate your patient’s fear and urges to avoid.
As we’ve discussed, PTSD is a disorder of avoidance.
If they didn’t avoid, they
wouldn’t have PTSD.
It’s the nature of the beast.
It’s helpful to review the rationale for treatment.
Remind them that avoidance
reduces anxiety in the short term, but in the long term, it prevents learning.
For
example, motor vehicle crashes, MVCs, are unfortunately very common in the U.S.
But luckily, most people who are involved in an MVC don’t end up with PTSD.
One
reason for this is that when they get back in the car and nothing bad happens and
then nothing bad happens in the car the next day and the next and so on, they and
their bodies learn that the MVC was a single bad event
but it doesn’t mean that every
time they get into the car they will crash.
If they avoid getting back in the car, they
don’t get a chance to learn this, and the fear festers.
Remind them that memories aren’t dangerous.
Although it will feel bad to think
about what happened, the memory can’t hurt you.
What does it teach your body if
you avoid or escape?
It teaches your body you’re right—it is dangerous.
I can’t
handle it.
I feel better when I’m not doing it because it means I’m safe.
Use analogies to support the rationale.
For example, 1 analogy that we use is living in
a cave.
So, avoidance is like living in a cave where the patient retreated to heal from
the trauma.
It makes sense to retreat to heal.
But if you don’t go back out, it feels like
everything outside the cave is dangerous.
If you only go out quickly, running to gather
food, carrying a big stick ready to protect yourself,
then running back into the cave
and feeling as if you just narrowly escaped danger again,
it reinforces the view that
everything outside the cave is dangerous.
What would you have to do to learn that
outside the cave is not dangerous?
Maybe sit at the entrance to the cave for an
hour—long enough to observe that nothing bad happens and for the anxiety to
decrease—then every day to venture a little farther away from the cave, always
staying out long enough to really see that there is no danger, not feeling relief or
safety when you come back to the cave.
Review the reasons that the patient sought treatment for PTSD.
Ask them to list some
of these reasons.
If they leave out important ones, you can use motivational
interviewing techniques to get them to list some more
or you can remind them with a
nudge.
For example, “What would your wife say if she were here?
How do PTSD
symptoms interfere with your life satisfaction?
How do you wish you could take your
life back from PTSD?” Review the progress that your patient has already made.
This is particularly why it’s
so important to carefully construct the in vivo exposure hierarchy and pick items for
homework that they’re likely to complete successfully.
You will want to come back to
this to demonstrate the power of exposure when done correctly.
You can ask,
“Remind me, what was the first thing you did for in vivo
exposure?” Patient: “Get in
my car and drive around the neighborhood.” Therapist: “And how did that go for
you?” Patient: “Well.” Therapist: “Can you tell me why it went well?” Patient:
“Obviously, I hadn’t driven since the crash and hadn’t
driven the car after it was
repaired.
So, I was very nervous.
We decided that I would just drive around my
neighborhood in the middle of the day when there weren’t likely to be many cars
around or kids around.
I did it like we talked about.
I drove around the same stretch
over and over for close to an hour until I felt more comfortable.
And it was okay.”
You can use examples of prior success and elicit from the patient why it was
successful and also elicit what was different about
times it wasn’t so successful.
Provide a lot of support and encouragement.
If this were easy, the patient would
already have done it.
If they could do it on their own, they would have.
This is PTSD.
You might want to schedule intersession phone contact to provide support and
discuss homework progress.
You can have them email you when they’ve completed
an exposure assignment.
You can have them schedule it into their phone or computer
calendar.
If you need to conduct exposure with them in the session, do it.
I ride with a lot of
patients on the interstate.
If it doesn’t have to be you, who else can ride with them?
Or who else can be with them for the next step of an exposure?
Ask them to text,
email, or call that person while they’re in the session with you and set up an
exposure date to hold them accountable.
Problem solve solutions to concrete obstacles to compliance with therapy.
If they
can’t get privacy at home or get away from the kids, go sit in their car to practice
imaginal exposure.
If they say they really don’t want to start dating yet, for example,
say, “That’s fine.
You can still set up a profile on a dating app.” Be creative.
Be
persistent.
But be compassionate and kind.
You are working with them against the
PTSD.
It’s going to be important to maintain the focus on PTSD.
If the initial assessment
determined PTSD to be primary, maintain the focus on PTSD with periodic
reassessment of other problem areas.
Comorbidity of other psychiatric disorders with
chronic PTSD is high.
Patients with chronic PTSD often face multiple life stressors.
Crises during treatment are common.
I have had patients literally crying in the waiting
room and then when I ask what’s going on and it seems to be
the crisis du jour, I tell
them the best thing I can do for them is stick to the
agenda we agreed to and then I
do.
And after, when I ask the patient how she felt, it was almost always better.
And
when I ask what she learned, it was some version of “I can be upset and do it
anyway.” I teach that to my patient.
I teach it to my children.
You can be anxious and
do it anyway.
Self-destructive impulse control problems such as alcohol or substance abuse binges,
risky behaviors, are often related to PTSD.
So again, the best thing we can do is to
treat their PTSD.
If a crisis arises without imminent risk, remind the patient
that adhering to treatment
and thereby decreasing PTSD and associated symptoms is the best help you can give.
I might tell them, “You came to me to treat your PTSD and
that’s what we’re going to
do.
These other problems will be easier to handle when your
PTSD is interfering less.”
I’ve even gotten a little more forceful if I think it’s
appropriate and I’ve told patients,
“Not on my watch.
You came to me for help and I take that responsibility seriously.
So, I’m going to help the best way I know how and that’s by treating your PTSD.”
Clearly state support for the patient’s desire to recover from PTSD.
Applaud healthy coping and homework effort.
If appropriate, externalize crises as
related to PTSD.
Predict that these situations will improve as their PTSD improves.
The overall aim is to provide emotional support through
the crisis, yet keeping PTSD
as the major focus of treatment.
I tell people very directly when I know they have
stressful lives that I will help them maintain a focus on their PTSD.
Keep in mind that CBT interventions—such as prolonged exposure, SIT [stress
inoculation training], CPT [cognitive processing therapy],
cognitive therapy—all of
these CBT interventions for PTSD also reduce depression,
anxiety, anger, and guilt.
CBT seems to have broad effects on negative emotions
beyond those targeted by the
treatment.
When we reduce their PTSD and depression, it often helps other problems such as
substance misuse or abuse.
Key points from this video: That PTSD is a disorder of avoidance.
Remind them
avoidance reduces anxiety in the short term, but in the long term, it prevents
learning.
Be creative.
Be persistent.
But be compassionate and kind.
You’re working
with them against the PTSD.
Maintain the focus on PTSD.
Teach them you can be anxious and do it anyway.