In honor of Veteran's Day - All about PTSD (it's not just for veterans)

I know you've heard a fair amount about PTSD or posttraumatic stress disorder lately: there's an alarming number of men and women returning from war with symptoms that often go unnoticed until something disturbing happens and the disorder is often blamed as one of the key reasons many veterans end up homeless and/or addicted to drugs or alcohol. But what exactly is PTSD and how does one get it?

Let's start with the "trauma" portion of the disorder. PTSD is defined by the Mayo clinic as: "A mental health condition that's triggered by a terrifying event." What's significant here is the phrase "terrifying event". The experience of combat is no doubt terrifying, but others things can be terrifying, too. Physical abuse, sexual abuse, abandonment, car accidents, workplace accidents, even verbal abuse - these can all be traumatic events. What's even more notable is that these events do not have to happen to you directly in order to cause symptoms of PTSD. The Diagnostic and Statistical Manual of Mental Disorder (DSM 5) notes that if you witness a traumatic event, learn about terrible trauma that happened to someone close to you, or if you are exposed to the details of trauma over and over again as part of your job, you can develop PTSD. In short, anyone can get PTSD.

The symptoms are where the "stress" part comes in. Symptoms heard of most often include flashbacks, nightmares, or recurring, intrusive memories of the traumatic event. You know all those old jokes about guys having "flashbacks of 'nam"? Yeah, that's PTSD and really, it's not so funny. Other, less commonly known signs are:

•  Avoidance of the location where the traumatic event occurred or of situations that remind the person of the event
• Avoidance of the memories (often achieved by some form of intoxication)
• Anger and/or irritability "out of nowhere"
• Hypervigilance - always on alert, over-observant
• Easily startled or jumpy at things related to or unrelated to the traumatic event
• Physical reactions to reminders of trauma, such as elevated heart rate, sweating, or gastrointestinal problems
• Sleeplessness
• Problems concentrating
• Recklessness
• Withdrawing from social situations
• Feeling detached from others
• Persistent negative emotions or negative view of the world or self ("I am a terrible person; the world is a terrible place)
• Blaming oneself for the traumatic event

This is A LOT, I know; much of this can also be identified with anxiety and depression (often diagnosed alongside PTSD).  However, if you find yourself or someone you love demonstrating any of these symptoms or simply not functioning how you/they used to, it's time to reach out for help.

Veterans and civilians can find more information about PTSD, including how to get help on the National Center for PTSD's website. We hear a lot about how little is done for veterans, but the VA is paying attention to PTSD - they're even starting to hire marriage and family therapists! You can also check out my previous blog about finding a good therapist. I've included links to several sites on that post - try to find someone that specializes in PTSD or trauma.

The number one best thing to do it about it is to tell someone. You can't drink it away; you can't make it go away on your own; you need support and someone who knows how to treat this. Just like soldiers need their brothers and sisters to successfully navigate the battlefield, we need others to successfully navigate life.

Ch-ch-ch-ch-changes

As I stated in one of my previous posts, I don't handle change well. What's funny is I get bored pretty easily, so I crave change quite often. But when a big transition creeps up on me, I get uncomfortable and a bit scared. I think a lot of people do this: we swing between periods of excitement and apprehension when we make big decisions, like changing jobs, starting or ending a relationship, moving to a new apartment, house, state, or country, or embarking on a new creative project. I find that I, and many people I know, tend to act as if everything is fine when going through these changes - like we feel that expressions of fear or tentativeness will somehow cause things to fall apart. Sometimes we "fake it" because we know the change is bad for us. Sometimes we "fake it" because we know the new thing is really good for us and we're just afraid to do it. Regardless of the situation, I've come to believe that expressing the nervousness to my partner or to a close friend helps tremendously. I find it offers perspective, usually helping to either ease my mind or encouraging me to contemplate the decision further. Sometimes even just saying "I'm nervous about this" and having someone else say "I know, it'll be ok" can help tremendously.

This practice of recognizing and expressing anxiety is in line with cognitive behavioral therapy, which helps people to change their thoughts and behaviors. Anxiety is one of the most interesting emotions to conquer because it perpetuates itself: we feel anxious and the symptoms of anxiety scare us; we don't want to feel anxious, so we try to ignore it or suppress it, but the symptoms persist and the feeling of fear is heightened, often accompanied by thoughts of "I'm going crazy", "People will think I'm crazy", "I'll never get this done if I can't stop feeling this way", "I'm weak if I can't control this", and so on. Working to alter these thoughts in a way that gives us the understanding that anxiety is common, normal, and "OK to feel" does something amazing: it quells the anxiety. Eventually, we're no longer anxious that we're anxious and feeling alright with our emotions allows them to be easily processed. 

Major change is one of my biggest anxiety triggers, but it is not the only one. No matter what the anxiety causing situation, I've learned to recognize, accept, breathe through it, and discuss it with others when necessary and appropriate. I'm curious, do you have trouble with change, too? How do you handle it and other anxiety inducing situations?

Is that how you REALLY feel?

When it comes to couples, a lot of people talk about "communication". Often we hear "A good relationship is all about communication" from advice givers or "We just didn't communicate" from recently broken hearts. Here's the thing: it's not that you communicate - because we all do, even when we're not speaking - it's how you communicate.

In love relationships, communication gets complicated. Because we've fallen intimately in love with someone, and they with us, we often expect them to know exactly what we need at all times. Why is it that we expect so much? I'm not completely sure why. Much of it has to do with attachment style, which dictates how we interact with others, but the rest seems to defy logic. Many times, we ask our partners to be superhumans - to behave in ways that are only agreeable to us and our wants and needs. If they don't, we get angry or upset and many times our partners have no idea why. Then they react, usually by either fighting back, going silent, or defending themselves in some other way. That's an all-too-familiar pattern that often brings couples to therapy.

Let's look at it a little closer with an example. I'll use wife and husband here to avoid confusion, but this could be any iteration of a love relationship: wife and wife, boyfriend and girlfriend, husband and husband, etc.

A husband is patiently waiting for his wife to get home from work. He knows she gets home around 5:30. She has had a particularly stressful week, so he decides to make her a surprise dinner which will be ready right when she gets home. 5:30 rolls around... no wife. 5:45, he calls her cell and she doesn't answer. 6:00 and now he's really worried, pacing the floor, wondering if she got into an accident or worse. He calls several times and goes through all the horrible scenarios in his head, getting very anxious and concerned. At 6:30, his wife walks in the door looking perfectly fine. Before she can speak, her husband goes off, yelling about how inconsiderate she is, how the dinner is ruined, and how much she clearly does not care about him or his time. Instead of telling her husband about the long promotion conversation she had with her boss in the lobby and how her cell phone was dead, the wife says something like "You're being ridiculous! How was I supposed to know? You NEVER cook. I'm sure it was awful, anyway." and storms upstairs to the bedroom. Both partners are now pissed at each other over what is essentially "being late for dinner".

So, are these people communicating? They sure are, but they're communicating what Sue Johnson, one of the founders of emotionally focused therapy calls "secondary emotions".  These are the defensive emotions that come out of what is expected from your partner, but not the ones that started the process in the first place. In our example, the husband was scared about what could have happened to his wife and then hurt that she was fine, but did not tell him she would be late. The wife was then hurt that she was yelled at and accused of not loving her husband as soon as she walked in the door. She was probably also quite disappointed that she could not share her exciting news with her husband.  If this couple had communicated their primary emotions, they might have avoided an argument or could have at least had a more productive one. If the husband said something like "I'm so relieved to see you! I was so worried. Why didn't you call?" The wife likely would likely have immediately apologized and then shared her story.

I'm willing to bet this sounds familiar to you. I've done it and still do, although I tend to catch myself a lot more often nowadays. It's a hard cycle to break and we're human: sometimes we just go off without thinking about it. Here's a tip on how to become a bit more self-aware: when you're angry or upset with your partner, think about the situation - the interactional cycle - that caused you to feel this way. Are you hurt by something she said? Are you afraid he will leave you because of something he did? Do you feel lonely or unwanted? If so, try communicating that emotion instead of yelling, crying, or shutting your partner out. Or try to consider the situation for a moment: are you expecting your partner to read your mind? For example, are you upset because she is behaving in a way that she should know would hurt your feelings, even though she's trying to do something good? As I've said before, S L O W  D O W N, think before you react, and ask for what you REALLY need. State how you REALLY feel, before all those fight or flight mechanisms stepped in. If that's too much for you, take a step back, check the defensiveness rising in you, and see how you might soften your reaction. You may even determine that the anger is completely unnecessary and happily go on with your day! (Seriously, it's happened to me before). Now, this is not to say that anger or sadness are inappropriate emotions, but you'll be surprised at how productive a conversation can be when it starts out with a certain softness, with a statement of personal need or desire, instead of blaming, nagging, or walking away.

Five ways to get your money's worth from your therapist

I know, therapy is expensive. Like I said: it's helpful to think of it as an investment. You're investing in your self or your relationship or your family. You're giving your life a tune-up. It all costs money. You're putting yourself in the hands of a professional in order to do so. Someone who has been educated and trained for, at the very least, 5 years if he or she is licensed. This person should know their stuff and that can be intimidating. BUT, it doesn't mean your therapist should be telling you what to do and it doesn't mean you can't trust your gut. In fact, your counselor should be encouraging you to trust and depend upon yourself. Here's a short  list of advice on getting your money's worth from therapy:

1. Ask questions, debate points, and give feedback Ask for what you need. If you don't understand something your therapist says, ask. If you disagree with something she says, say so. This doesn't mean you shouldn't listen to her, but when something feels inherently wrong, just way off from who you are, SAY SOMETHING. It doesn't help you at all to stay mute on the subjects that really rile you up. Again, your therapist is not your friend; she is providing you with a service. Having said that, however you must understand that you also have to...

2. Do your homework Many therapists gives little assignments to their clients. You might be asked to journal something or to complete a questionnaire online or to notice a behavior or thought process during the week. Try your best to do these assignments. They are given to you for a reason and completing them shows your therapist how committed you are to working on yourself or your relationship. If you don't complete your homework, let your therapist know why. Perhaps something needs to be changed about it or perhaps it's telling you something about yourself or your counselor.

3. Listen Listen to what your therapist has to say, the questions he asks, and the insights he might have. He may have some very valuable points to make or inquires. However, your counselor should not be doing most of the talking. If this is the case, speak up. You're there to talk about your life, not listen to your therapist drone on because...

4. You're the expert I know this sounds strange, but you are the expert on your own life and relationships. A good therapist should never act as if she knows what's best for you. A good therapist does not give advice. I repeat:A good therapist does not give advice. A good therapist asks good questions, gives good insight and good suggestions. The point of therapy is to give you (or you and your partner or you and your family) the ability to make the right decisions for yourself, not to make you dependent on your therapist.

5. Work through the discomfort Part of any therapy, whether it be individual, couple, or family, is building self-awareness. With this comes the uncomfortableness of dealing with emotions you'd just rather not feel. Things like sadness, anger, guilt, and hurt. Things that make you feel vulnerable. I can say this from my own experience with therapy: Lean into the discomfort. Because when you come out the other side you've learned more about yourself, more about how you affect others, more about what works for you and what doesn't, and more about the joy you can have. Be gentle with yourself, though. Handle what you can at the times you can. Take it slowly.

I know we hear this all the time, but it is a worthy adage: Take risks. It's the best thing you can do for your brain and for your heart. You've taken the risk to go seek help, now take the risk to make the most of it.

Congratulations, you've found your therapist! Now what?

It's the 1st session. You're nervous, asking yourself questions like "What will she be like? Will he think we're crazy? What have I gotten myself into?" If you've never been to a therapist before, it's like walking into a small room with a stranger who has agreed to take your money to provide you with a product you know little about. It can be weird and feel awkward. You're taking a big risk entrusting someone else with your problems, with your life. And kudos to you for your courage! I want to try to make it all a little less daunting, so here's a brief guide of what to expect when you walk into a therapist's office for the first time:

When you get there, you will be greeted with the usual pleasantries and a bit of small talk, but eventually you'll have to get serious. Your therapist will soon ask "what brings you here today?" You may have talked about it on the phone prior to your appointment, but some version of this question will be posed to bring the focus to exactly why you're paying to be there. Attempt to be as honest as you comfortably can be. It's natural to feel strange about telling someone you've never met your most hurtful problems. You don't have to say everything, just try to be truthful. This can be extremely difficult when you've come to therapy with a spouse and it's the therapist's responsibility to help you feel as safe as possible in his or her space. This is YOUR time. Use it wisely.

When you come to therapy for the first time, at some point in the session you will be asked to sign confidentiality agreements and other documents. Your therapist should verbally describe the important points of the documents to you. If you do not understand certain parts of the document, be sure to ask. Again, this is for you, not the therapist. Good questions to ask include:

• Does anyone else have access to your files?
• What do I do in an emergency?
• Who will take over for you when you go on vacation or if something were to happen to you?
• Will I/we have a diagnosis?
• Can I/we give feedback?
• What theories do you use? - I, for example, am quite interested in emotionally-focused therapy. Common approaches are cognitive-behavioral, solution-focused, and systems theory (for couples or families).
• What sort of education or experience do you have with my/our specific problem(s)?

The therapist may also administer certain assessments or tests, depending on what your complaint is.

If you're going with your spouse or partner, it is also important to ask who the client is. Is it the person who called or is it the couple as a whole? You might also want to ask about confidentiality if you have individual sessions. Will the therapist keep secrets or is everything out the open, no matter what? My advice here, don't put your therapist in the position of keeping secrets from your spouse. You're in therapy - be honest. This is probably the one place in your life where you won't be judged for what you do, within reason.

NOTE: a therapist MUST report to the authorities if a person presents a reasonable threat to him/herself or others or if child or elder abuse is evident. There is also no statute of limitations on sexual abuse, so a therapist must report a living offender even if the abuse occurred many years ago. This should be discussed in your first session, as well. The therapist does not have a duty to report domestic abuse and may or may not be willing to work with abusive couples. This should be established before you get to your first session, though.

A really good therapist will have you feeling safe and heard within the first one to two sessions. If after the second session, you are not feeling this way, speak up! I hear stories all the time about people sticking with a therapist who they feel "did me no good" for long periods of time or who "liked my partner better than me". My first response is always: "Did you say anything?" or "Why did you keep going??" Again, it's weird - you're telling this person so much about your life. It's SO personal. Keep this in mind, though: your therapist is not your friend. You are paying this person to provide you with a service. You have the right to complain or seek help elsewhere (you can even ask your therapist for a referral) if you don't feel like your needs are being met. Do this, and you will get the most you can out of the therapeutic process.

Have any other great advice for therapy newbies? Let it loose in the comments section!

Next week: More on getting your money's worth in therapy