laurie-gallo--she-her-_1_09-11-2024_123707

Dr. Lori Gallo is a clinical psychologist who focuses on trauma recovery and healing. She became interested in trauma due to her work with individuals suffering from substance use disorders who were self-medicating their trauma. Her personal connection to trauma, as her father was a Vietnam War veteran with no support or diagnosis, led her to improve trauma-informed care for underserved populations. She works at Montefiore Medical Center in the Bronx, addressing community violence and systemic traumas. Dr. Gallo emphasizes the importance of creating a safe therapeutic environment, using affirming language, and dosing interventions based on the client's needs. Universal screening for trauma is also a key principle in trauma-informed care. However, not all individuals who have experienced trauma will develop PTSD, so it is important to assess their needs and provide care without re-traumatization. Absolutely. Thanks for having me. Great. Sure. So, my name is Dr. Lori Gallo. I am a clinical psychologist. My pronouns are she, her. And I came to the work in terms of trauma recovery and healing initially through my first work in graduate school was focusing on individuals who were suffering from substance use disorders. And just seeing how so many of those individuals who we were treating, right, were actually like self-medicating issues with trauma really led me to have a curiosity about wanting to look at the core of the difficulties, right, and going back to the history of the pain that was really driving their substance use. And then really kind of if I were to ask myself, like, where does that curiosity and that desire to want to heal individuals with trauma likely comes back to what we know about trauma being intergenerational in nature? Just saying that I was born in 1975 and my father is a Vietnam War veteran and was in the Vietnam War as a combat veteran in the 1970s. And PTSD did not become a diagnosis until the year 1980. So I grew up in a household in which someone was suffering with difficulties associated with what we now would call post-traumatic stress disorder and alcohol use difficulties. And yet there was no name for that and there were no services. And so having a deep connection to understanding the suffering that stems from trauma and the lack of services for people who experience trauma has led me to want to really commit my career to improving the services that we have for underserved populations. And at one point, veterans were underserved populations and it's through their advocacy that PTSD became a diagnosis. And in my career, I've been working at Montefiore Medical Center, which is in the Bronx, New York. Shout out to the Bronx, which is beautiful in its diversity and also has its struggles in terms of facing economic hardships and other struggles. They face a lot of community violence and trauma and systemic traumas. And so it's been really my clinical home base and one that I've had a deep commitment to improving trauma-informed care and trauma-focused treatment in my work. So this is deeply, deeply heartfelt, values-based work for me. I'm going to let you go ahead and I'm going to let you go ahead and I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. 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I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. I'm going to let you go ahead and get back to work. Some specific principles that have been named by SAMHSA, which is the Substance Abuse and Mental Health Administration, that are six guiding principles to a trauma-informed approach. That includes creating a sense of safety, trustworthiness and transparency, collaboration and mutuality, empowerment, voice and choice, as well as ensuring that we're addressing cultural, historical and gender issues. There's a lot, I think, to unpack there. Maybe I can just start with safety in terms of how I address safety in the room. I think first and foremost is just trying to address safety in the therapeutic space, just in physical safety. Just trying to be mindful of things like the environment in which you're seeing clients. If you're seeing people face-to-face, does it feel safe for people to, if they're driving, park their car? Or can they get to your agency or clinic in a way that feels safe to them? How is your office arranged in terms of where is the individual's chair? Where are you sitting? Just even how is the room arranged, right? Are you sitting in a way that is blocking access to the door? Things like that can really make a difference in terms of a person feeling safe in the physical space. Thinking about emotional safety. How are you showing up as a therapist in the room? Trying to be grounded, trying to tend to our own nervous system. If we are dysregulated, then that's going to create a sense of unsafety for the person that we're meeting with. Making sure that we are regulated, whether that's doing our own coping skills or meditations or whatever we need to do to take care of ourselves, to be present, making sure that we can hold space for people. I think also being mindful of our language. Being affirming in our language, using invitational language. Being mindful of power dynamics that can come across in our language. Inviting people. Would you be willing to share with me what brought you here today? I'm curious about what you might be experiencing. Rather than using language that might be more coercive in nature and have more of a demanding tone so that it feels more like you're inviting them into the space and you're having a curiosity around them. That starts to create a sense of safety. Also body language. Even if you're in telehealth, how close are you to the screen? How far away? If you're face-to-face, are you crossing your legs? Are you crossing your arms? Having an open, calm body language. Trying not to shake your leg too much. Trying to exhibit signs of receptivity. Also dosing your interventions based on shared decision-making and where they are. I think oftentimes therapists can become quite eager. Seeing on the referral, oh, this person's coming in for PTSD. Let me just jump right in. Oh, this is fantastic. I have all these skills for them. And that might not be where that person is. So really reading where the person is and being willing to be flexible to kind of meet them where they're at. And holding in mind that creating safety is really the essential first component along with creating that therapeutic alliance. So I think that's one of the main principles, I think, that's really essential in trauma-informed care. Yeah. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Sure. One of the principles also of trauma-informed care is universal screening. And so one of the things that I do and any trauma-informed system would be doing is universal screening. So that would be having people filling out a questionnaire that is screening for the experience of trauma. And so that can be things such as the life experiences scale or depending on the population that you're working with. It could be something like the ACEs, the adverse childhood experiences, or perhaps the Philadelphia ACEs. If you're working with a population that experiences more community level adverse experiences in addition to more of the interpersonal ones. And then asking whether or not they'd be willing to kind of talk to you about those things. And I think it's essential to also hold in mind, first of all, that just because someone has experienced a traumatic event, the majority of people who have experienced a traumatic event will not go on to develop PTSD. And so I think that, first and foremost, is something for people to keep in mind. Because I think there is an assumption that because someone has experienced a trauma, that they must talk about it. And so a tenant of trauma-focused treatment, right, is processing the trauma. And that's related if someone actually meets criteria for PTSD. But not all people who have a trauma history actually meet criteria for PTSD. So I would invite people to first kind of check in with their own assumptions about why they're thinking it's essential for this person to talk about the details. So you can know it by universally screening. So you know kind of what their history is, which is important. So you can be providing trauma-informed care so that you are not providing care in a way that is going to lead to re-traumatization. And you need to do further assessment to determine whether or not the person actually meets criteria for PTSD. So I think that's one thing that I would want to name. The second thing is I would also want to be knowing, like, when was the trauma? Is this a trauma that happened 20 years ago? Or is this a trauma that is acute, that maybe just happened a week ago? So if this is a trauma that just happened a week ago, then I would definitely not in any way be pushing someone. I mean, regardless of when the trauma was, I would not be pushing someone to talk about their trauma. You know, one quote that I think is an extremely powerful one, and I invite people to hold on to Judith Herman's quote, is any intervention, no matter how much we as therapists think that it is useful, if it takes power away from the patient, it is inherently not trauma-informed. And so if a patient does not want to talk about their trauma, then not forcing them to do so. So shifting more, if it's a recent trauma, shifting more to psychological first aid, right, psychoeducation. And, you know, trying to understand, I think, creating safety is essentially like listening to them, right? So through empowerment, voice, and choice, like going back to some of those trauma-informed principles, right, by empowering the patient that you're hearing them, like, I don't want to talk about my trauma history, giving them that choice. So that is actually empowering. And then depending on what their diagnosis is and what is actually a treatment plan, you can then share with them what the recommendations are moving forward. Thank you. Great. Thank you. Absolutely. I mean, there's a reason why, even though there are obvious flaws with the DSM, but there's a reason why there's a 30-day period that we don't diagnose people with PTSD. Because, you know, having certain reactions in those first 30 days is completely normal. To have those reactions to a traumatic event is being human. So we also don't want to pathologize just being, having a response to a psychological injury. And holding space that different people will respond differently. And there's a whole other group of people that we see post-traumatic growth, which is a whole other category, right, where we see people that actually have resilience and actually have post-traumatic growth in terms of, like, meaning-making and spirituality. And not everybody goes on to develop symptoms of suffering related to the trauma. Sure. I mean, I think one of the things is just how I show up, right, just how I show up as a therapist. Again, with the use of universal screening, I think it's showing that I'm curious. And then, again, using invitational language. But then giving choice, right? Are they willing to share more about their experience? And if they are, lovely. And if they're not, then that's okay. And respecting their choice. And that's such an important piece, right, is, like, for people to have the experience of being heard. And, you know, some might say, well, that's reinforcing avoidance. And what I would say is that that's actually reinforcing someone setting a boundary and being heard. And one of the things that happens in trauma is disempowerment and not being heard. And so one of the foundational things in the early stages of therapy, in my mind, is creating a strong therapeutic alliance. And for the person to really, for us to build an alliance, we're working together, and there's a sense of trust. So for me, that's way more important than to be just jumping on avoidance, right? And I think that's where, in my opinion, some people get too hooked on theory and kind of lose sight of the person that's in front of them. Not to say that at some point you don't provide psychoeducation around avoidance and how it maintains symptoms if someone does have PTSD. But then you kind of work together as a team and kind of say, partner together. How can we work together to address this avoidance that's keeping you stuck? But again, that comes back to that collaboration and mutuality, right? That we're a team, we're working together. So really kind of recognizing that healing happens in the context of a relationship. And so really working hard to create a strong therapeutic alliance and knowing that I have to earn that. But that is not a given. And so being consistent, showing up on time, following through with what I'm saying. And as you were saying before, like, if there are nuances, right, if I shake my leg, just kind of being transparent and being like, oh, sorry, you know, I'm shaking my leg. Or, you know, sorry if I seem a little off today. I have a headache. So if it seems like I'm not as present as usual, I apologize. Because as you were saying, people who have experienced trauma can be much more hypervigilant to cues, right, especially like facial cues. So just being human, right? And recognizing that that trust needs to be earned over time. And being willing to put in the time. All right. All right. Absolutely. And I think just it also speaks to us being mindful of the power dynamics that are inherently present in the room. So, you know, even if, you know, most of us come to this work because we care, right, and because we want to help people heal. And there are inherent power dynamics that are present between a therapist and a client. And the client feels that, right? And that can be extraordinarily triggering. And so for you in the role of therapist to be questioning them in and of itself can be extremely triggering for people who have been abused, particularly by people with, you know, developmental trauma who have been abused by caretakers or who have been abused in systems or people who are, have identities that are marginalized and are systemically abused, right, where it's not necessarily safe to trust the doctor. It's not necessarily safe to trust the police. That being mindful of, like, holding those things in mind and recognizing that power dynamic and doing our best to try to dismantle that power dynamic as much as we can. And, you know, one of the metaphors from ACT that I love and I share with the people that I work with is kind of naming, inviting them. Like, let's talk about how it might be useful for us to work together. And talking about the ACT metaphor of two mountains, right? So the two mountain metaphor is essentially like you, you know, you're over there kind of climbing the mountain of your life, right? As you're climbing your mountain, there are difficulties, there are crevasses, there are rocks and twists and turns, right, that are very, very challenging. And I am over here on my mountain, right? And I have my own challenges, right? And I'm not saying that I have the same type of challenges. Your mountain might have a lot more bumpy roads than mine, right? And I don't have any magic, right? It's not like I have the answers to how to climb mountains. However, I do, I can like look over and see the perspective of you climbing your mountain and say, hey, it might be useful for you to maybe take a left step over here. Or I wonder if maybe you kind of take a right step. And knowing that I'm over here climbing my mountain, supporting you, right, and being there for you when you stumble and figuring it out together. And I find that there's something about that metaphor, which is an ACT metaphor, that number one, allows you to build in structural inequalities for people where you can validate that, yes, I might hold a lot of power and privilege in my life that they do not hold by making their mountain have more like complications. But also sharing the universality that we're both human. Like I'm also a human. I'm inherently flawed. And it's not like I have magic. And I'm deeply invested in helping you navigate the challenges of climbing your mountain. Thank you. Thank you. Sure. Thank you. Thank you. And I just want to name that although it's not named in the DSM, but racism-related stress and cultural stress and trauma related to gender identity is something that myself and I think a lot of scholars in the field of trauma are starting to really kind of push for this to be seen as a criterion A trauma. The way the DSM is written, it wouldn't be. I would invite people to see that as something that you can diagnose people with PTSD. There is something called the unrest, which is specifically for racism-related PTSD. So just wanting to kind of put that out there. And there are other recommendations I can maybe kind of share with you, resources if people want to read about. I just wanted to put that on the radar for people because I think it's just so important. But irrespective, if people are presenting with a primary diagnosis of PTSD and they do not want to talk about their trauma, I always start with just psychoeducation. So I provide psychoeducation about trauma and the impacts of trauma. So you can provide psychoeducation about how trauma impacts their sleep, how it impacts their functioning, how it impacts the way they think, and how it impacts their relationships. So you can provide psychoeducation. You can also provide psychoeducation that the treatments that are in terms of trauma-focused treatments that are evidence-based are EMDR, prolonged exposure, and cognitive processing therapy. One of the metaphors that I like to use with patients is I'll often say something like, you know, let's imagine you have a wound on your hand. And it's a pretty deep wound here. And it really hurts, really hurts. But you're afraid to get stitches because you're afraid that the stitches are going to hurt. So you just keep like slapping Band-Aids on. Just slapping Band-Aids on because you're like, oh, I just, I really don't want to get those stitches. What do you think is going to happen over time? If you just keep slapping on stitches, but you're not cleaning it out, you're not, you know, you're not getting the stitches, what's going to happen? And kind of walking them through socratically how, you know, it's likely to get infected, it's not going to heal, right? And it's understandable. You don't want to get the stitches. You don't want to clean it out because it hurts and you're afraid. And so you're avoiding by just kind of piling on in the short term these Band-Aids, right? However, the longer you kind of avoid, the more it's probably going to get infected. And so what do we need to do to heal it? Well, we might have to go in there and kind of clean it out now, right? And that's likely going to hurt and you get the stitches. And it hurts in the short term, but in the long run, it facilitates healing. You will always have a scar that will remind you of what happened. However, how is that scar different than having that open wound or the wound that's sort of like festering? So just kind of share that with them and say, I get it. If you're in a place where you just want to slap on Band-Aids, we can do that, right? That's your choice. But I just want to let you know that in the long run, there's still going to be this stuff that's not going away. So here are your choices. We can either, I can help you kind of put on some Band-Aids to help you just kind of get through, right? Or we can do the hard work of cleaning out the wound. What do you want to do? Yeah. Exactly. And a lot of people, I'm sorry to interrupt you, a lot of people will say, can I do the Band-Aids right now? Because I don't feel ready to do that other thing right now. But can I do the Band-Aids now and do the other thing later? It's like, absolutely. Absolutely. We can do the Band-Aids right now. And then when you feel ready, let's revisit doing that deeper work. Absolutely. Thank you. Thank you. Thank you. Sure. I guess just in terms of like how I came to that work is, you know, I'm trained in a variety of trauma-focused treatments, like cognitive processing therapy, prolonged exposure, CBT plus TE. And what I was finding is that there were some folks who, in spite of doing all of these trauma-focused treatments, so they were willing to do them, but there was still like a sense of like stuckness. And particularly I was finding this with individuals that I would say present with more like a complex PTSD presentation, as well as individuals that had probably more like the dissociative subtype of PTSD. And I guess the reading that's most connected to this would be Bethel van der Kolk's The Body Keeps the Score, which, you know, I highly recommend people read, which really is talking about more of like a bottom-up, the sort of bottom-up aspects of trauma. So, you know, there's so much of trauma that is stored in our bodies that, in terms of memories and bodily sensations, that language cannot really capture. And so many of our psychotherapies are language-based, right? So we're doing trauma processing, but through language. However, memories and trauma memories and experiences can be stored like from a neurological kind of perspective in the body and in the brain, but there's no language attached to that. So we know, right, for example, when someone goes into fight or flight, the executive functioning, the frontal lobe goes offline, right? And it's more the amygdala and hippocampus that's firing. And so trying to tap into interventions that can get to that sort of body-based, bottom-up experience versus top-down, which is more cognitive, is something that was really intriguing to me. And so there have been several now randomized controlled trials looking at using trauma-sensitive yoga, which, you know, often when people think about, and it's trauma-centered, trauma-sensitive yoga at the Justice Center in Boston, you know, often when people think about yoga, they think about it as being relaxing, right, or getting grounded and centered. And that's not what this is about. But what this is about is about helping people use movement as a way to practice choice-making, as a way to practice interception. And so it's really an exposure-based intervention where individuals who are engaging in the intervention are using movement as a way to kind of work through their emotions and process their emotional experiences rather than using language. And it's just been incredibly powerful to see it as an addition in my toolkit with the patients that I work with. And the research is growing. With, like, a recent randomized controlled trial where trauma-sensitive yoga had equal outcomes to cognitive processing therapy, which is a gold standard, and there was less dropout in the trauma-centered, trauma-sensitive yoga group. And, again, people are not talking about their trauma. What they're doing is they're moving. There is no physical touch. There's the use of invitational language, a focus on interoception, choice-making. It's a really incredible and really powerful treatment where people learn to start moving their bodies and working through experiences using body movement. Thank you. Thank you. Thank you. And it's another option for people who don't want to talk about the trauma, right? And for people who either can't or don't want to talk about the trauma. Thank you. Again, like, I think I would echo back to Judith Herman's quote of any intervention that takes, you know, power away from the client is inherently not trauma-informed. That being said, I think a lot of trainees, myself included, were trained that, like, if a person has PTSD and they do not want to do the treatment, then we do not treat them. And there are some, like, specialty clinics and there are some providers, I think, that would still stand by that. That being said, I think that my perspective is that it's broadened and become more flexible over the years and that my thoughts about what does it mean to treat trauma has become more flexible. But I think in my mind it used to be what it meant to treat trauma was to be actually actively implementing a protocol. However, now, you know, with however many, you know, years of experience, I've come to realize that there's so much healing that happens in the context of the relationship and that, you know, if you get into a tug of war with individuals and trying to force them to engage in a protocol or are rejecting of them because they do not want to engage in a protocol, I think that that's actually harmful and can actually be re-traumatizing, right? Here someone is coming asking for help and they're being told, you're not doing it the way that I want you to be doing it. And so you will not be helped. And to me, that is re-traumatizing. And, right, I think we can hold the dialectic of still going back to that band-aid metaphor. We can still share with people, hey, I truly believe for your ultimate healing, again, if they meet criteria for PTSD, for your ultimate healing, I deeply believe that this is the type of treatment that would be helpful for your long-term healing. And they also get it if you're not ready to do that. So what makes sense, like, what are your goals? Like, where are you at right now? And so patient autonomy, like, is essential. Like, patient-centered treatment, right? So that is essential. Like, holistic, trying to think of individuals as holistic beings rather than diagnoses. And that's, I think, one of the downsides of treatment manuals and diagnoses is that we lose sight that this is a human being that's sitting across from us. And I myself, at times, can get hooked by thoughts of, well, I'm not being a good therapist if I'm not doing a PTSD protocol because this patient has PTSD. However, I think that's a very reductionistic kind of rigid way of viewing things. And it's very driven by systems like the DSM and treatment protocols, which we do have research that shows that, like, when people overly adhere to manuals, there are worse outcomes than when people are focusing more on the therapeutic relationship and still implementing the manual. And so I personally think that delivering evidence-based care still needs to happen in a patient-centered, holistic manner. And so that would be my invitation to therapists is that you can still be doing that while still holding on to that notion that this is a human being sitting across from you that is suffering and holding on to, like, why did you come to this work? Like, why is this work important to you? And how is you trying to impose your agenda really in the service of what is best for them in this moment if you really zoom out and think about dependence of trauma-informed care? Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. And I will say that there are times, and this has happened in my career, where someone's PTSD is so severe that they do need a higher level of care and that they have needed, let's say, to go inpatient for trauma processing work, right? That outpatient work. We've done DBT. We've done a variety of Band-Aids, let's say. And in spite of that, there are still a lot of dangerous behaviors that are indicating that, like, an outpatient level of care is not safe for them and that trauma processing is actually indicated for them to be able to heal in a way to be safe enough. And it's still done in a collaborative manner where the person and I mutually decided that an inpatient stay, because what was the barrier? We were like, well, what is the barrier to them doing trauma-focused work? And it was really that whenever we tried to do trauma-focused work, they would become severely suicidal and dangerous. And so there was a decision for them to go inpatient. And so I think that being open to those things and being mindful that there might be circumstances where it might not be safe to do it on an outpatient basis as well. Thank you. Thank you. Thank you. Absolutely. So if someone wants to make that as a personal choice for their private practice to only work with people who are in, if we think about, like, stages of change. So if it is your personal preference to only work with people who are in sort of the readiness stage of change, that can be your choice. And as you were saying, Shana, like, you can apply trauma-informed principles when delivering the message. And my guess is that if you are, again, going back to just in terms of, like, trauma-informed principles, my guess is that if that is the case, the way in which you are marketing yourself is probably very clear on your website. Like, in terms of, like, your website or your advertising or how you have your Psychology Today profile, that my guess is that you are making it clear that that's how you are operating. And, you know, typically those programs are very clear in their assessments, in their assessment phases, about what the requirements are to be in their program. So there aren't necessarily a lot of head-to-head studies. That really informs which trauma-focused treatments. We do know that the trauma-focused psychotherapies that have the most research support are prolonged exposure, cognitive processing therapy, and EMDR. So those are the kind of front-line treatments. So just from, like, a clinical, like, in my clinical decision-making, the way that I go about it is, again, like, shared decision-making, is that I'm thinking – I'm just describing the treatments to people. So EMDR, I think, is a treatment that a lot of people – you have to have, like, a special certification. Some hospitals, like our – you know, our hospital, it's not one – a treatment, like, you have to have a special, like, level of certification to be able to deliver it. So in our system, prolonged exposure and cognitive processing therapy were the two options. And so, like, laying out to the person and describing the two treatments to them and what they involve. So describing how prolonged exposure involves both in vivo and imaginal exposure to memories of the traumatic events. And then describing a little bit about cognitive processing therapy and including both with and without the written component. So there is evidence that you could just do CPTC. So that's cognitive processing therapy with just the cognitive component. So they don't have to do the written portion. There is research showing that you can do that. So describing that to them. And then seeing which one they prefer. That's usually where I'm starting. And then I'm also thinking, as a clinician, there are a few things I'm holding in mind when I'm thinking about what might be a good fit for someone. So if, for example, someone has a lot of guilt and shame and depressive symptoms, then I might kind of encourage them to be thinking about how cognitive processing therapy might be helpful to them. Because we know that cognitive therapy in general can be useful for depression. And we can also target the guilt and shame. And there's evidence, there's research supporting that. And so although, yes, you know, prolonged exposure, it may eventually target that. It doesn't, like, intentionally target that. Whereas in cognitive processing therapy, we're teaching them cognitive restructuring skills that is intentionally targeting the guilt and the shame. So that's one thing that I'm keeping in mind. If the person does not have distinct memories, like if they really have fuzzy memories, they're not very clear, then I'm also going to be thinking more, kind of sharing with them, this is one reason why cognitive processing therapy might be more useful. Because with prolonged exposure, if they don't, when we're doing the imaginal exposure, if they don't have a vivid memory, then it's difficult to have them to fully engage and benefit from that. Oh, sorry, can I add one more thing? I would also say that if someone has high reactivity, so in terms of, like, their symptom profile and their PTSD symptoms, if they have, like, a lot of reactivity in their brain, if they have, like, a lot of reactivity symptoms, so, you know, when they are faced with certain cues, they're having, like, panic attacks, and they're avoiding a lot of behavioral avoidance, then I would be thinking prolonged exposure. So that would be another thing to be keeping in mind for prolonged exposure. Okay. Thank you. Okay. Although I will say, you know, in terms of, like, diagnoses, in the DSM, they would still be diagnosed with PTSD. The National Center for PTSD would say that you would still offer the same treatments for them. For me, the things I'm thinking about, again, is, like, readiness. So are they ready? Do they have the skill set to be able to engage in cognitive processing therapy or prolonged exposure? So oftentimes with complex PTSD, what we can see are things like intense emotion dysregulation, difficulties with distress tolerance, and maybe some other behaviors like non-suicidal self-injury or suicidal ideation or substance use that may get in the way of them effectively engaging in one of those other trauma-focused behaviors. Again, not to say that you can't do those trauma-focused treatments with people who are suicidal or who have substance use. You can, as long as it's managed, because we know that people are often self-medicating, so we want to treat the trauma in order to reduce their substance use. But if someone is really presenting with a collective set of symptoms that is leading to difficulties and impairment in their functioning, that you feel like they would benefit from some skill development to be able to engage. Because we want them, when we're doing trauma-focused treatment, we want to keep them within, like, that window of tolerance. The window of tolerance is really kind of like that place of where there is an affective increase, where there is new learning occurring. But we don't want to go outside of that, where essentially there's just re-traumatization occurring. They really need to have skills to be able to regulate their emotions during these exposure-based therapies or these trauma-focused treatments that are going to be increasing their emotions because we're having them come in contact with traumatic material. If they don't have adequate skills to stay within the zone of tolerance, then I'm thinking, okay, I want to give them some skills first. So that's where I might be thinking about a therapy like STAIR, which is Skills, Training, and Affective and Interpersonal Regulations. So STAIR is a treatment that was created by Marilyn Kloetcher and others, and it includes both emotion regulation and kind of distress tolerance as well as interpersonal skills. And you can do those skills alone in addition to, like, a narrative therapy component, or you can just do the skills component. And then also there's DBT with PE, so Dialectical Behavior Therapy, and then followed by Prolonged Exposure, which has been created by Melanie Harned's group. So those would be the things that I would be thinking about, is giving people skills to better regulate their emotions and tolerate distress so they can stay within that window of tolerance before kind of proceeding with a trauma-focused treatment. Thank you. Sure. So I can think about a particular person that I worked with for – I mean, this has come up – I would say that it's actually more the norm, that people initially did not want to talk about their trauma. So I would say for the most part, people select the Band-Aid approach and then transition. There have been a few cases where people are ready to kind of jump in, but I would say in my experience, it's been more the Band-Aid approach, which I can talk more about what that looks like. But with this person, he was in his 30s, identified as a cisgender black man who was presenting with PTSD related to childhood trauma, as well as some trauma related to community violence related to residing in the Bronx. And racism related trauma. And he also met criteria for major depressive disorder and polysubstance use. And initially, he came to me following a serious suicide attempt, and we kind of mutually decided that given the severity of his suicidal ideation and polysubstance use, that it kind of made sense to focus on stabilization. And so the first year of treatment really was doing a course of DBT and really focusing on skills building. And so he did a year long of DBT, of like a standard DBT, attending DBT group, seeing me for individual DBT. And then at that point, once his suicidal ideation had reduced, hadn't resolved, but had reduced significantly, his substance use had reduced significantly, taking a harm reduction approach, not an abstinence-based model, but had reduced significantly. But a lot of it was still being driven by the PTSD. And so at that point, we sort of, again, in an ongoing basis, like having that model and that kind of metaphor of the Band-Aids, right, it's like, okay, we've done the Band-Aids for a while now. And it seems like we might be kind of hitting a point where you might be ready to start doing some wound care. What do you think? And having discussions and like doing like a preparatory phase. So actually like having several sessions preparing to start the treatment. So, you know, talking about like what are concerns, so using a DBT skill called coping ahead, you know, even creating like specific safety plans, following exposure sessions, and really kind of being intentional about the transition, trying to enlist a supportive other. So he had someone in his life that he felt was someone he could go to, not necessarily to talk about his trauma, but that if he was feeling overwhelmed after an exposure session, someone that he could go to for support. So we enlisted that person as a support. That person actually attended a session. I was able to, with consent, actually provide psychoeducation about PTSD. Because we know that like people with PTSD are so isolated and having support and social support is so incredibly important. And so having someone in their life that understands what they're going through is incredibly important. And so being able to provide some psychoeducation about PTSD and how that person could be supportive during difficult times was an incredible important part of the preparatory phase as well. And I think having all of those things in place allowed us to then kind of step into the prolonged exposure phase. And as you said, his hierarchy, right, he had multiple traumatic events. And so really leaving it up to his choice with what memory to start with. And I usually encourage people to start with a memory that has like a subjective unit of distress score that's at least a 40. Because we want to have like some activation. So trying to pick something that's like a 4 on a 0 to 10 or a 40. So there's some activation in terms of trying to help him kind of select one and then kind of working our way. Okay. Yep. Okay. Sure. So one of the sort of accepted approaches is called like patient-centered, or sorry, present-centered therapy. So it's actually a non-trauma-focused alternative for PTSD. And it actually came about because it was seen as an active control in research. And basically in present-centered therapy, what you're doing is, you know, you're basically targeting what are maladaptive relational patterns or negative behaviors that the person might be engaging in. You're providing psychoeducation regarding the impact of trauma on their current life. And you're teaching them like the use of like problem-solving strategies. So things that I'm like targeting would be things like sleep hygiene. So we know in PTSD, sleep is so important. It's very negatively impacted. And it's incredibly important that when people are not sleeping, their PTSD gets worse. So doing sleep hygiene techniques with people. Also doing like activity scheduling with people. So trying to decrease avoidance, right? So avoidance is highly prevalent in people with PTSD, as well as avoidance of, you know, an inability to kind of feel positive emotions. So trying to do pleasant activity scheduling, trying to, you know, do a lot of ACT. So, you know, bringing in like what are their values, what's deeply important to them, and trying to get them to connect to things that are deeply important to them. Just try to just get them to be reengaging in life. Also problem-solving techniques. So when people have experienced trauma, you know, one of the trauma responses, you know, there's fight or flight. But we often forget about the freeze and fawn responses, right, which is like the tendency to kind of freeze and kind of shut down. And that can be, you know, something that they're experiencing throughout their week when stressful situations are coming up. So they might just be having difficulty managing their life. So, you know, just targeting day-to-day problem-solving and stress management. Offering things like relaxation techniques, like deep breathing, encouraging exercise, and like healthy nutrition, things that we know that are helpful in terms of like emotion regulation. You know, meditation is something that has been helpful, found to be helpful for PTSD, particularly loving kindness and self-compassion. It's something to just be thoughtful about in terms of the potential for a backdraft for people who have experienced PTSD and trauma. Sometimes experiencing self-compassion might actually make their, they may experience as aversive. And then also doing longer meditations can actually make PTSD worse. So sometimes doing more like mindful walking or, you know, mindful movement can be more available for people. And then helping people like cope with like relationship difficulties, increasing social support. So, again, the tendency to avoid and social withdrawal. So trying to increase social connectedness, increasing connection to, you know, what matters to them. And then if it's available to them, like trying to create some meaning-making, right? Like can they find some meaning in life? And then, of course, this would be, so those are some of the like overall, you know, kind of anxiety management techniques, right? But then, you know, depending on what their presentations are, you know, some people with PTSD can present with anger outbursts. So you might want to, you know, offer some like anger management strategies. Or if they're presenting with prominently like panic attacks, you might want to offer them some panic, you know, strategies, like education about panic attacks and how to manage panic attacks. And then like any other presenting problem that they're coming to treatment, right? So if they're coming to treatment for another presenting problem, trying to weave that into the work as well. Yeah. And just to say that things like present-center therapy, right, and acceptance and commitment therapy, although they're not considered frontline treatments, they are, they have good outcomes with PTSD. And so you're still helping them heal. It's just, you know, it may not kind of get at the core of things, but you're still helping them move through stages of recovery. And that's where I think it's helpful, you know, think about like Judith Herman's like stages of recovery and thinking about like where someone is in their readiness, right? That they may be in stage one, which is like skill building, right? And stage two is the mourning and processing. And then stage three is more the meaning making and kind of connections. And so it's also okay, right, to have, I think, trying to think more flexibly and more continuously about trauma care rather than this kind of bifurcation of like either people are in or out of trauma treatment, trying to see it more on a continuum. Okay. Sure. Thank you again for having me. It's been lovely to be in conversation with you as always. And people can find me on my website, which is www.actforthriving, which is my private practice where I offer individual psychotherapy, as well as trainings in trauma-informed care and acceptance and commitment therapy. Yeah. All right. Thank you.