Addiction Medicine Made Easy | Fighting back against addiction

Trauma Therapy Explained with Dr. Jessica Cooper

• Casey Grover, MD, FACEP, FASAM

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Trauma is a crucial aspect of addiction treatment, often serving as the underlying cause for substance use. In this illuminating interview with trauma therapist Dr. Jessica Cooper, we explore the mechanics of trauma therapy and how it helps people heal from devastating experiences.

• Breaking down trauma therapy into three essential phases: establishing safety, processing memories, and reconnection/integration
• Understanding how childhood trauma creates patterns that can lead to re-traumatization in adulthood
• Exploring the "fawn" trauma response (people-pleasing) alongside the better-known fight/flight/freeze responses
• Examining the differences in approach between single-incident trauma vs. complex, repeated trauma
• Creating a trauma timeline with "stones" (traumatic events) and "flowers" (protective factors)
• Processing traumatic memories through multiple perspectives: factual, sensory, emotional, and belief-based
• Recognizing signs of healing while understanding recovery is non-linear
• Using creative expression as a powerful tool in trauma recovery
• Developing a collaborative approach to trauma treatment

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department, seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. Today's episode focuses on trauma, which is a crucial aspect of addiction treatment. I recently sat down with Dr Jessica Cooper, a trauma therapist in my area, to discuss how trauma therapy actually works to help people heal. Let's get started, Okay, Well, I am so excited to talk to you today. Why don't you start by telling me who you are and what you do?

Speaker 2:

for about 16 years now and my background I've worked in different settings including community mental health, domestic violence, shelters, a lot of experience with university mental health, working at counseling centers, mostly in the UC system, and then for the last three years I have been based here in Monterey and have a private practice and I specialize in working with survivors of trauma and, in particular, survivors of interpersonal violence, so of different forms of abuse and assault, intimate partner abuse. I also have a lot of clients who have experienced different forms of trauma and trauma related to marginalized identities they hold so racially based trauma, trauma related to immigration, you know, to being LGBTQ, some experience working with veterans as well and currently doing individual therapy with teens and adults, but a lot of background with group therapy for trauma survivors too.

Speaker 1:

So I like to think about things in a very simple way. The emergency department there's so much you got to know. You got to keep it simple. So, at the 10,000 foot level, what I do as an addiction doctor is I help people go from regulating themselves with substances to self-regulating. How would you describe trauma therapy at that 10,000-foot level?

Speaker 2:

Yeah, well, I will refer to the great Judith Herman and her book on trauma and recovery that I really see the stages of trauma therapy first about establishing safety and trust in the therapeutic relationship, then this process of remembrance and mourning around the trauma and what has been taken away, and ultimately moving towards reconnection with community and society and an integration of the selves. People often feel like they were one self before that experience and then another self afterwards.

Speaker 1:

So let's start with those three parts of what you do Talk to me about the first part, which I believe you said was safety.

Speaker 2:

Yes, yeah, so starting with establishing safety and you know a lot of that really is establishing myself as a safe person for the client. So someone who's experienced trauma has had this profound loss of control over their lives. So, even just starting with how therapy is going to work, they are really in charge of the content and pacing of our sessions and then I'm there as a kind of a guide. I also think that establishing safety is looking at. Often, clients are coming to me in crisis. They are coping and using survival skills the best they know.

Speaker 1:

Or substances.

Speaker 2:

I was about to say, yeah, that often it is unhealthy in ways of coping and a lot of that trauma survivors related to alcohol and drug abuse, different forms of self-harm relationships with reenactment of trauma in them. So before getting into more of the actual processing of trauma memories and I do start with an overview of what they've experienced, but that first stage is much more skills-based of how can I really help in providing some grounding and self-soothing and emotional regulation skills and to address ways that they may not feel safe within their relationships.

Speaker 1:

It's my belief that if they're still in their trauma, as in they're still in a domestic violence relationship, it's not appropriate really to start trauma therapy. Would you agree with that and, if not, tell me what I'm missing?

Speaker 2:

Well, I do think that's appropriate to start therapy.

Speaker 1:

I would agree.

Speaker 2:

Yeah, with a pint while they're still experiencing intimate partner abuse. But it's true that the focus wouldn't be on like let's really go through these memories in detail with one another. Yeah, it's tricky working with someone who is still within an abusive relationship, that maybe the most important thing I can do as a therapist is to be compassionate and nonjudgmental. But you know it's hard when I'm very concerned about their safety and, to be honest, and probably are not going to be in therapy for very long. So it is this process around safety planning and really validating what's going on in that relationship that they do not deserve and attempting to empower them ultimately to make choices around the safety or how to leave that relationship.

Speaker 1:

Let's dig into this a little bit, because I think you said it beautifully, that a person might not be in a place in their life where they are safe, but they still would benefit from therapy. Do you counsel people differently while they're in their trauma, about how to manage the trauma as it's happening?

Speaker 2:

that seems like it's a really weird position to be in as a therapist yeah, I mean it may be a a weird position but you know I'm definitely part of the work and and often someone who is experiencing intimate partner abuse has a much longer trauma history. So maybe we would be working around how the child abuse and neglect that they experienced then made them vulnerable to intimate partner abuse and how that intimate partner abuse can even be like a kind of reenactment of past trauma.

Speaker 1:

Okay, so that makes sense. So even if someone comes to you in a difficult relationship, you still have stuff to work on earlier in their life that's maybe primed them to be victims of trauma in the future.

Speaker 2:

Yeah, it's often the case.

Speaker 1:

Yeah, it's the same thing with my patients is I have some of them that can't remember when the trauma started, only that at some point the sexual assault stopped. Yeah, yeah, very dark. Talk to me about how being a victim as a child of trauma sets a person up to be a victim as an adult.

Speaker 2:

Yeah, that's a good question. Yeah, that's a good question. To be a victim of child abuse is really an experience of betrayal that someone who is supposed to be a safe adult, supposed to be a caregiver, instead is harming that child. I talk a lot with my adult clients who experienced trauma in childhood about survival skills, of really trying to honor the survival skills that they developed in childhood while looking in adulthood at what may no longer be serving them. Of course, yeah. So for example, it might be a survival skill in childhood of really how to please and appease someone who is abusing them, but then if we're talking about an adult romantic relationship and those are still the same dynamics where it's all about what the other person needs and they're not allowed to have needs and emotions Then that survival skill they got through childhood is no longer serving them in the present.

Speaker 1:

Are you talking about the so-called fawn of fight flight freeze and fawn Exactly. Let's unpack fawn, because I heard about this recently from a colleague of mine.

Speaker 2:

Yeah, you don't hear as much about fawning.

Speaker 1:

Yes, this is new to me.

Speaker 2:

Right. People are familiar with fight or flight. Or freeze yeah, with freeze, but fawning, which can also be known as the please and appease response, that someone who their trauma response is through fawning is probably going to be really conflict avoidance. They're so attuned to the person who is harming them and attempting to prevent further harm, but you know that really it is then this relationship that often is like a reenactment of trauma. Is then this relationship that often is a reenactment of trauma.

Speaker 1:

One of my colleagues who I think should have a PhD at this point she is just so extremely intelligent about trauma, having lived it herself was describing to me that a lot of what the brain does around trauma is. It has an unresolved trauma and it will seek out similar situation because it needs that closure. In other words, if a parent sexually assaults child, they'll choose abuse in relationships as an adult because they need to close that childhood trauma. Is that on the right track?

Speaker 2:

of childhood trauma, but reenactment of trauma is very common, like that wish you know of. Well, maybe I can be different, or I can make this other person be different this time to get them to stop harming me. And I think it's important to talk with clients about reenactment of trauma when you have a sense that that's happening, because they probably on some level, like really feel ashamed and are confused and blaming themselves. For example, like why am I staying in this relationship with someone who is hurting me so badly?

Speaker 1:

Yes, I'm thinking about a lot of my patients that have that reenactment of childhood abuse, multiple abusive relationships. I met a psychiatrist from Harvard who spoke on my podcast about trauma and he described trauma like a snowball as it rolls down the hill, it picks up speed and more snow and more trauma. And he described trauma like a snowball as it rolls down the hill. It picks up speed and more snow and more trauma and it just grows. What do you see in your practice around that?

Speaker 2:

Yeah, I like that description. Yeah, that does feel apt and I don't know if this is quite answering your question, but a lot of what I also do with clients is looking for where are their stuck points in healing, like in trauma reenactment, which so frequently are connected to that experience of shame. So there can be shame around, like initially experiencing a trauma, but often even more shame around how it then continues to impact somebody in order that they haven't gotten over it yet. Or like the ways that someone is coping, for example, with abuse of alcohol and drugs are then resulting in more levels of trauma and of shame.

Speaker 1:

How do you, as a clinician with a focus on trauma, differentiate between a singular big event, let's say a car accident, versus repetitive traumas over time? What's different in your approach between those two?

Speaker 2:

Great question and the diagnostic manual that we both use, the DSM-5, only has a PTSD diagnosis. It does not have a complex PTSD diagnosis, although I really think that it should. So the complex PTSD diagnosis is for repeated and prolonged trauma experiences and often in a relationship with someone who that person is supposed to be able to trust. So there are some key differences in how that can present and where to focus in therapy. Like, specifically with complex PTSD, there can be such interpersonal issues around trust and how to determine whether another person is trustworthy, or also difficulty with trusting the self, like being able to trust one's intuition about other people. I also think that, working with someone who has complex PTSD, that it is really important over time to move from that safety stage of treatment into more of the processing and narrative around traumatic experiences.

Speaker 1:

That sounds like a great segue to talk about part two of what you said, which is the processing. So this is the black box for me. I understand safety and I understand merging on the other side, but what happens in the middle?

Speaker 2:

So in the middle and I do talk with clients about really the need to acknowledge and to mourn what has been taken away by the experience of trauma, for example, a sense of safety, the ability to be intimate with others, how to really trust I find it really useful with the processing stage of trauma therapy to have a client create a timeline for me and I like with narrative exposure therapy, that it's having clients do a lifeline with what's called stones on one side and flowers on the other side, so that the stones are those painful traumatic experiences. So, for example, if I'm working with someone who's 25 years old, they do a timeline of their life where they're indicating okay, here are the years that I was experiencing child abuse, these are the years that I was closeted, this is when bullying was taking place, etc. And then on the other side, the flowers are more of those protective factors, the good things going on in that person's life or sort of the protective factors.

Speaker 1:

Would that be like a protected big brother or a mentor or a sport or something Exactly?

Speaker 2:

Yeah, and so much of resilience is about how someone finds the safe adults or safe people in their life or activities that they're good at to also have sense of self-worth. So then having this kind of map that we keep referring back to throughout therapy we work with one of these particular experiences of trauma and going through the memories in stages. So starting first with a traumatic memory kind of like talking to a reporter with as much detail as possible who, what, when, where, etc. Then going back through that traumatic memory together in different ways. So one way could be much more of a focus on senses and body sensations. Then it could be going through this memory with more of an emphasis on their interpretations of the event and the beliefs that came out of the trauma and also really going through with the emotions.

Speaker 2:

And often when I'm starting like that processing with someone, well, actually I find that either when someone is recounting a traumatic memory, they might be really emotionally dysregulated and in tears throughout it and perhaps we're having to pause and do grounding with one another, or there can be a level of numbing and dissociation, of course, that it's as if they're telling a story that happened to somebody else, and really avoidance of experiencing those painful emotions but ultimately in that stage of therapy we have to be able to get to the morning. We have to be able to get to those painful emotions that now this person is safe enough to be able to feel like what they haven't been able to feel in the past.

Speaker 1:

So do you just let your client pick whichever is the biggest rock and start with that or the rock that they're worried the most about? Or how do you pick which rock to start with? I'm sorry, you call them stones or rocks.

Speaker 2:

Stones, stones. My apologies, can't be either. Okay so, yeah so, same concept.

Speaker 1:

Which stone do you pick?

Speaker 2:

Yeah, Well, we make that decision together. And, yeah, going back to, they are in charge of content and pacing of the sessions and I am the guide walking alongside them. Typically it's either the worst stone or going through it chronologically with each other. And another reason that I do like to have this timeline is, let's say, I'm working with someone because they recently experienced a sexual assault, but then I recognize, oh, this is someone who had to take care of alcoholic parents and they got into this terrible car accident at one point. Just that. So often if you're looking at just one trauma, you're missing a lot of context of earlier traumas that they had experienced.

Speaker 1:

So we talked briefly just before we started that I have PTSD from my career in the emergency department and it's interesting I've been just thinking about my own traumas and a young woman who hung herself is the one that keeps coming to mind. I actually had flashbacks, if we've been sitting here, of seeing her in the literature marks. That makes perfect sense to really allow the client to say this is the one that's on my mind the most. I want to talk about this. I'm assuming you allow your clients to self-regulate and choose about what seems to be most urgent or on their mind the most, or do you ever have times where you say that's too intense? We're not ready to do that yet.

Speaker 2:

Yes and yes.

Speaker 1:

Of course. Yeah, I figured.

Speaker 2:

Yeah. Yeah and there are different schools of thought on this that another trauma therapist might say no, you really have to go through establishing safety stage before getting to discussion of a worst trauma, like over what we're talking about. If someone comes in and they want to start with talking about a worst traumatic memory, I'm probably going to go with that, while saving at least 10 minutes in that session for some grounding and then figuring out what the plan should be to take care of themselves that night. But there have been times that I've stopped someone. For example, if I know that someone is suicidal, then it's really not appropriate for us to start by going into the worst trauma that can be really dangerous. I then, of course, would stop that person and just explain my rationale about how we need to start in establishing safety before getting to the worst of it together.

Speaker 1:

So it sounds like and I'm a fitness person, that's what keeps me sane. I'm almost thinking of what you do as like a workout. You do a warmup, you have an intense workout, you do a cool-down and then you have a recovery. Does that sound like a fair way to think about it?

Speaker 2:

your sessions- yes, yeah, and I do really think that it's important to not just leave someone in a worst traumatic memory of like, oh, we're out of time, we're going to talk.

Speaker 1:

I was going to ask you about that, please, please, log in.

Speaker 2:

Yeah, we'll pick this back up next week. That's why I can be really adamant around saving the last 10 minutes of the session. Are you open to my leading you through a grounding exercise right now and I give different options with grounding exercises and what is the plan for this evening Just acknowledging that we've opened a lot up together and so there can then be a flare up of PTSD symptoms. Here's why I also like to have started with more of that skills-based approach, because then we're able to reference what has been helpful for them with self-soothing and grounding and having that be a part of the plan of what they're going to do that night.

Speaker 1:

And in terms of what this processing actually looks like practically? Right, and in terms of what this processing actually looks like practically, I'm assuming it varies person to person, but would you say it's roughly an average of 20 sessions, 50 sessions, 200 sessions. Let's imagine one person has a singular trauma, a bad car accident, they were almost killed. For that sort of singular event, big T trauma would you estimate roughly how many sessions a person needs to process?

Speaker 2:

Someone with a singular trauma. It is possible that when we're in the processing part of therapy, maybe we would do that within five to 10 sessions I'm reluctant to put a specific number on it and I definitely have people who I've been working with for years around processing the trauma timelines, because there's so much for us to go through together.

Speaker 1:

Well, it's like you asking me, how long does it take someone to get sober? It's like, well, it depends. Correct Contrast for me, though. Let's say somebody again has this singular traumatic car accident event and someone else, a second person, has 10 years of sexual assault as a child. I'm assuming the second client is much more complicated. More sessions takes more time Overall. Obviously people are going to be different, but I'm assuming more trauma means more time to process. Is that about right?

Speaker 2:

Yeah, that's probably true. And also, what was the age that trauma began? If I'm working with someone who experienced 10 years of sexual abuse, they probably don't remember their life before trauma. If I'm working with someone who doesn't have a significant trauma history up until a terrible car accident, then they've had an opportunity to really develop their sense of who they are and what their coping skills are. It would also be a different approach with a car accident that probably part of what we would be doing would include exposure therapy. Someone who's been through a car accident natural for them to be frightened to drive again and avoiding driving.

Speaker 2:

So, with that person, I would work with them on establishing a hierarchy of their fears. Work with them on establishing a hierarchy of their fears, starting with actions that they can take to challenge avoidance, that are less scary, and then working up to what's more scary. So maybe we would start with them driving around a parking lot that's empty with a trusted person in the car, and then work their way up to a Los Angeles freeway at rush hour.

Speaker 1:

Well, the good news is the Los Angeles freeway is a rush hour. You don't go more than five miles an hour.

Speaker 2:

I spent a lot of time in Los Angeles freeways. I lived in LA for a decade. Yeah, I had a lot of experience with Los Angeles freeways too.

Speaker 1:

So I'm going to make a big jump here, because this is a question that comes up all the time for me and it sounds like the process of understanding this is similar to what you just described around driving after a car accident. But I have so many victims of sexual assault and as human beings we're wired to have close relationships and intimacy, and the process of dating and intimacy after sexual assault just seems insurmountable to me and I'm curious how you work with clients around that, because I would love my patients who've been sexually assaulted to heal and move on and find meaningful relationships and, if it's right for them, start families. But I don't even, can't even imagine what that's like.

Speaker 2:

Yeah Well, this is a good moment for me to include that. I am such a proponent of group therapy for survivors of sexual assault and abuse, especially like when they are in more of that, building connections, you know, phase of therapy, and when I would lead support groups for survivors. Whenever it would be the group session that we would talk about dating and sex and intimacy. You could sort of feel this sense of oh well, this is the hardest part of recovery for many of them, but also like what's bringing them to the group, what they want to change the most. And you know that these clients we would talk about how, for so many survivors of sexual assault, there's sex, there's intimacy.

Speaker 2:

But the challenge is really around experiencing sex with intimacy, Of course, and sexual assault can often cause different extremes in behavior. So one survivor might really avoid sex and intimacy even if they want that. Another one might be in sexual relationships where there can be a reenactment of trauma or it's risky or not safe for them in some way. So a lot of what I do with clients is acknowledging the difficulties, talking about triggers and handling triggers and when that does come up during sex and also what their rights are.

Speaker 2:

For example, like to not have sex when they don't actually want to have sex, or like, if they're having sex and are triggered or, for whatever reason, don't want to continue to have talked in advance with a partner about how the partner might be able to tell if it's not something that they can put into words that that is happening, and then the understanding of stopping and maybe, if they're open to it, some other type of physical intimacy. Also, often it's best to start with sex with one's self Masturbation.

Speaker 1:

Trying to understand what the body feels.

Speaker 2:

Yeah, really trying to get like reacquainted with the body, to have experiences of being in the body while aroused, rather than to be dissociated and having a sense of what they like and don't like, how to experience pleasure. And then, when it comes to sex with a partner, my clients can often be reluctant to tell the partner that they are a survivor of sexual assault or abuse, and it's a very difficult conversation to have with another person. I mean, talk about like really just the trust and bravery it takes to have that conversation. However, I think it's a really important conversation to have.

Speaker 1:

Absolutely. Yeah, I have a number of female patients that talked about becoming very promiscuous after being assaulted because they wanted to be in control. Talk to me about the various responses that you see in your clients after a trauma. Whether it's avoidance, whether it's again sexual assault is unique. The promiscuousness. But let's say, somebody has a car accident, do they not drive? Do they only let someone else drive? Do they speed recklessly? What are some of the common responses of the brain trying to regain control after a trauma?

Speaker 2:

Yeah, most commonly it is avoidance.

Speaker 1:

Oh, that makes sense.

Speaker 2:

You know, like the core components of PTSD are Avoidance yeah, some sort of intrusive, re-experiencing avoidance alterations to mood and cognition and nervous system hyper arousal I still don't walk through the er.

Speaker 1:

Yes, yeah, I'll avoid it. I'll go all the way around the hospital to avoid the er. I love my colleagues in the year, but I totally avoid it avoidance is that natural response.

Speaker 2:

But when it's avoidance of something that is not actually dangerous, not a threat, even though the body still experiences it as a threat, then avoidance can just be so limiting and is sort of reinforcing oh that this threat really is something to be feared.

Speaker 1:

So we've talked about establishing safety as part one. The processing itself is part two and I'm sure we could do two to three hours on the processing, the third part. You talked about merging and reintegrating. What's that like?

Speaker 2:

merging and reintegrating. What's that like? Yes, so you know that third part around reconnection and integration is a stage that is more present and future-oriented, so it can be much more focused on healthy relationships with other people, which often involves a lot of boundary setting and knowing about interpersonal rights and, after trauma, how to recognize ways that you are actually the same person and often where I go with that, like it is around, like core values that remain unchanged, for example, like a core compassionate to other people. It can also be this recognition of this trauma happened. It was outside of this person's control and the ways that they had to grow and change to cope with what happened, like that they like those things about themselves, wouldn't want to give that up. So it can also be recognizing, for example, like becoming a much more honest person in relationships. But, yeah, it really tends to be this stage where we're not focused on looking into the past anymore. We're more focused on the present and the life that survivor wants to build.

Speaker 1:

So let me see if I can make this make sense in my simple former ER doc brain. In stage one, people are in a bad place destructive behavior, bad environment. They're often so focused on others like their aggressor. Stage two after we achieve safety, we learn to self-regulate. It seems like step three is almost learning how to actually think about others and yourself together in a healthy way.

Speaker 2:

Does that sounday yeah, definitely, I think that's a good way of describing it. And yeah, the stage three thing To some extent it was also maintenance of change, Of course, At that point that overall my client is more stable, happier in their life, but probably still experiencing flare-up of PTSD symptoms, especially during periods of heightened stress or loss or transition. So the part of therapy is also around recognizing that's a normal part of recovery and practicing how to take care of themselves when PTSD flare-ups occur and to recognize that actually they really have made a lot of progress.

Speaker 1:

When my daughter had asthma as a child. She's grown out of it, but in order to go to school she had to have an asthma action plan signed by her pediatrician. You had the green light, one puff of the inhaler. The yellow light was three puffs of the inhaler, wait a few minutes, do this. The red light was take oral medicine and then do this and the crisis was called 911. Do you create that granular level of a relapse prevention or a you-just-got-triggered prevention plan? How do you set people up to self-regulate in the future With how to self-regulate?

Speaker 2:

in the future With how to self-regulate in the future. I do think a lot of that is psychoeducation around understanding what happens during a trigger response and then having the skills to be able to deal with that. So, to be more specific, I like the analogy that for a trauma survivor, a threat is experienced as if there is an ambulance siren going off next to them. For someone who hasn't experienced a lot of trauma, it can be more like oh, someone's cell phone alarm is going off in the other room, but it really is this different experience. So for a trauma survivor who's triggered, then some of what they're going to do is the self-talk around telling themselves how they actually are safe in that moment. But a lot of it is going to be grounding and self-soothing skills. So, for example, can be like a kind of physical grounding, of focusing on, like I'm sitting in this chair right now, all of the contact points between my body and the chair, my feet and the ground beneath me, ways to engage the senses, to be back into that present moment.

Speaker 1:

One thing you hinted at when we were just getting started was people actually mourning the loss of a former self. Do people change their names? Do they change their hair color? How do people emerge on the other side? What do people tend to do in your experience?

Speaker 2:

One way they do that is to get tattoos. Really, yeah, I don't think I've worked with anyone who changed their name through a trauma journey, unless they're trans, which is a whole.

Speaker 2:

Very unique yeah of course, yeah, which is different, but a lot of my clients at some point do get a tattoo, a tattoo. For example, I have a client that for her and for family members that when a hummingbird appears, you know that it's this reminder that, no matter how bad things get, you know that there's still beauty in the world. So then having this hummingbird tattoo is something that they can look at on their body and you'll have that memory. I've had other clients tattoo messages to themselves, like to remember to breathe. Another client who had a cabin tattooed, that was this symbol of how she's reclaimed ownership of her body as a safe place. So yeah, actually I got really common for my clients and I don't think it's ever something I've suggested, but many of them do get tattoos in later stages of their recovery of them do get tattoos in later stages of their recovery.

Speaker 1:

Two interesting reflections back on that. One of them is I mentioned a friend and colleague who is very knowledgeable about trauma and she's a victim of trauma herself, and she talked about tattooing was a way to take her body back to my body. It's interesting, though I had major depression in college, along with self-harm and an eating disorder, and I was going to get my dad's initials tattooed on my chest because my dad was in the process of dying of cancer, and that was a major part of what I was dealing with, and my psychiatrist said absolutely not. You will get one, then you will want two, then you will want three, then you will want four. He really recommended against it.

Speaker 2:

So did you get any tattoos?

Speaker 1:

No, I do not.

Speaker 2:

Still no tattoos.

Speaker 1:

No tattoos. I do have a couple of scars, and cutting and self-harming behavior is very interesting and we could spend another hour talking about that, but ironically my scar is in that spot where I was going to get my tattoo.

Speaker 2:

Yeah, I think I would have given you different advice if I had been your therapist at that time. It is true that when clients bring up tattoos that I suggest not making that choice impulsively, of taking some time to really consider. Do they want that tattoo? Maybe even like inking it on for a while. But yeah, I wouldn't tell someone. If you get one tattoo, you're just going to want more and more Interesting. Maybe you'll still get a tattoo, I don't know.

Speaker 1:

We'll see and then forgiveness. So again, a car accident is the word in that term. Is accident Presumably there's. Well, there may be someone at fault, but presumably it was a horrible thing that happened and a person recovers. But when someone harms another, when a person is the victim of physical, sexual, verbal, assault, abuse, whatever, how do you talk about forgiveness with the victim?

Speaker 2:

Yeah. So what I tell the victim is that the only forgiveness that needs to be a part of their healing and recovery is the forgiveness of themselves, which can be forgiving, blaming themselves for the trauma having happened. Often it's more forgiveness blaming themselves around the impact and how long that impact has lasted. I don't think that forgiving whoever caused the harm has to be a part of therapy, but if that is important to my clients, then I will work with them around that and, for example, I have a lot of conversations with clients who experienced abuse by a parent about how to hold both the harm that that parent caused and the empathy that they feel for that parent.

Speaker 2:

An intergenerational transmission of trauma is so common. So often my clients will be expressing well, my dad had been abandoned by a parent and was beaten by another parent, or had all this immigration trauma and getting to the US, etc. So, yeah, we just talk a lot about it's possible to hold both, like the recognition of the harm that was caused, along with empathy and perhaps forgiveness for that person. How do you take care of you hearing all these stories?

Speaker 1:

I really have to take care of myself.

Speaker 2:

You have to do yes, yeah. So I often remember I think it was my first week of grad school and my ethics professor saying well, you can't ever ask a client to do something that you wouldn't be willing to do yourself, and that honestly freaked me out. You know, I'm just I'm going to ask my clients to do so many difficult things, but I can't ask my clients to be taking good care of themselves if I'm not doing that myself. So I think it's really important as a trauma therapist to not go it alone. Although I am now an individual in private practice, I have a lot of great former colleagues and friends who are also trauma therapists, so I'm able to get support from them.

Speaker 2:

My husband's an amazing cook. He makes delicious meals. I have a really cute dog and cat. I appreciate getting to the point of my day that is more restorative. I'm also such a reader and film lover, so having ways to really immerse myself in something else. I am a compassionate meditation practitioner and facilitator too, which I really like to incorporate into therapy. My clients are open to that which I really like to incorporate into therapy and my clients are open to that. So, especially when I go back to where I lived before here in Santa Barbara and part of Mindful Heart Programming where I'd done my training. That just for an afternoon and being back in that space or at times like taking a longer in a meditation retreat is really restorative. And lastly, travel. I love travel. I also experience that is really restorative. And lastly, travel I love travel. I also experience that as very restorative. What percentage?

Speaker 1:

of therapists, would you say, have therapists themselves.

Speaker 2:

At some point should be all of us, I think the majority. I really appreciated that it was a requirement of my graduate program to do a year's worth of weekly therapy. I did much more than that myself, and I think both again, because I shouldn't ask if I want to do something I'm not willing to do myself.

Speaker 1:

It can be wonderful to have it be okay. This is really now my turn to unload and to receive caretaking from someone else who also just really relates to what it is that I do. So I've obviously asked you loads of my questions. You're the expert here. What have I missed?

Speaker 2:

What are important parts of managing trauma in what you do that we haven't talked about yet. Well, one of the questions that you had sent in advance of how can someone tell when they are healing I really like that question, so I just wanted to bring that into the conversation too. It's important to talk about the process of healing and to redefine together what healing looks like. It doesn't mean that PTSD symptoms are fully in remission permanently, and hopefully it means that they are going to really lessen intensity and in frequency. But just really knowing how healing is nonlinear, how often with therapy, and choosing to talk about all the scary stuff that someone might feel. Talk about all the scary stuff that someone might feel worse before they get better.

Speaker 2:

Yeah, I'm also always looking for the ways that I'm able to point out like well, when we first started meeting with one another, I really think that you would have reacted to this stressor in this way, and I'm hearing that you were able to handle it in this very different way. So, yeah, really bringing in the strengths as well, but, I think, a lot of discussion around what healing does and does not look like. I also think it's such a gift when my clients have artistic talent. I wish that I did. Talent, I wish that I did. But if they are able to have art or music or dance or writing be a part of their healing too.

Speaker 1:

A lot of my patients are very artistically minded. I keep encouraging them to put something on this blank wall here no takers yet, but the icon for my podcast is a painting by a friend of mine who died from overdose. I'm so sorry, no, no, well, thank you. I spoke at his funeral and he had shared his art with me while he was still alive. And I spoke at his funeral and I brought this painting that he had made before he ever knew me and shared it with me. And yeah, so people across the globe see his art and it helps his family have closure. So I love this idea of encouraging my patients to be as creative as possible. I think of processing trauma for my patients can be talk therapy, it can be journaling. It not like therapy, medicines, medical. I like kind of a person in their own environment being creative. It really seems to empower them, to show that they have value and uniqueness as a human being.

Speaker 2:

I hope so. I love that. That's a way that you remember your friend. My best friend died several years ago due to alcoholism, which is such a heartbreak. And yeah, in my office I do have a photo that she had taken of a mural with an eye in it and it does give me the sense of her watching over me. I have to say I will be definitely referring patients to you and you are welcome to refer patients to me in return.

Speaker 2:

How common is it in the therapy community was especially focused on working with interpersonal violence survivors, which I loved that opportunity for consultation and collaboration. Yeah, I think that a lot of therapists do focus on trauma and even if a therapist is not trauma-focused, they can still be trauma-informed, for example, actually asking about a client's trauma history at intake or holding that in mind and looking for the ways to bring that back into therapy when it feels relevant. And I would love to be able to refer to one another. I don't think I've said yet that I also think that ideally, trauma therapy is a team. You know that perhaps I'm doing individual therapy with someone. They're also in group therapy. They have a great trauma-sensitive psychiatrist. Maybe they're doing alcohol and drug counseling too. So both just in terms of not burning out as professionals, it's important to have that team and also for the client to have that kind of multidisciplinary support.

Speaker 1:

I will be a better doctor next week after talking to you. You're so kind. Any last thoughts that you want to leave?

Speaker 2:

us with. I just I appreciate the work that you're doing with this podcast and I really appreciate for any physicians and psychiatrists to be so trauma-sensitive that it's also part of trauma to often minimize the impact while really suffering or not make the connections like between the trauma and that present day suffering. So for you to have this podcast and to be having these conversations here with clients is so valuable.

Speaker 1:

It's funny we started with talking about safety and I'm going to finish us up by saying that's what we really try to create in this space is safety.

Speaker 2:

Yes, we have to be that trusted person Well said.

Speaker 1:

Well, I have to say thank you so much, I have learned so much, and may I invite you again for future topics?

Speaker 2:

I would be happy to return in the future Sounds good. May I invite you again for future topics? I would be happy to return in the future Sounds good.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives.

Speaker 2:

I'll see you next time.