Dr. Daniel Knoepflmacher (Host): Hello, and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research and other important topics on the mind. What you're about to hear is the second installment of a two-part series on trauma with our guest, Dr. Jessica Hartman.

In our first episode, we discussed what trauma is, how it impacts people over time, how structural factors lead to increased trauma among marginalized groups. And we discussed trauma-informed care, a systematic approach to this widespread problem. Thank you, Dr. Hartman, for coming back to continue this conversation.

Dr. Jessica Hartman: Thank you so much for welcoming me back. I'm so glad to be here.

Host: Well, discussing trauma can be demoralizing. The reason you do this work, and you talked about this in the first episode, is to help people learn to build resilience and thrive. In the last episode, you quoted a patient who thanked you for helping her find hope. Can you tell us what effective treatments are out there for people who are seeking help after experiencing a trauma?

Dr. Jessica Hartman: Absolutely. We're very fortunate in our field that we have many interventions available for individuals who have experienced a traumatic event. The interventions can be delivered via a variety of interventions, whether it's individual or in group context. In some cases, pharmacological or medication-based intervention might be incredibly helpful. The specific kind of treatment that's appropriate might vary a little bit depending on the nature of the event and sort of where the individual is at in that moment in time. So, for example, if you have a situation where a community experienced a large trauma, the appropriate intervention at that time might be something like psychological first aid, which is something that is often delivered by many different kinds of people, be it mental health professionals, schools, first responders.

So, a good example of this that we can think of is the Lahaina wildfires. So in that case, people experienced a very significant event and disruption. And in the immediate, some of their needs may have been things like access to shelter and food and medication. And at that point, the appropriate sort of course of action is to triage and address those needs, while also providing the support that's needed. In some cases, for individuals who've experienced a traumatic event, they might need to do some additional work through individual therapy or a group therapy format. In some cases, if they're struggling with PTSD, or in some cases as we've discussed, if they're not struggling with PTSD and yet they're just finding that they're experiencing a lot of symptoms that are impacting their life in a significant way.

And one thing I also think is important to mention is that regardless of this specific intervention, they all sort of have their unique elements and pieces, and yet there's a lot of commonality also in some of these approaches. And broadly speaking, I think the goals of any treatment are to help that individual reduce any symptoms that are impacting their functioning, increasing that person's resiliency, and improving connectedness and relationships are all really sort of core things that come up in all forms of trauma-focused therapy.

More specifically, some examples of individual therapy can include interventions such as trauma-focused cognitive behavioral therapy, or we love our short hands in this field, so that's often called TF-CBT; cognitive processing therapy or CPT, which is an intervention that we typically see used with adults and now teenagers; DBT prolonged exposure or DBT PE, which was adapted from a DBT-focused lens. There's also eye movement desensitization and reprocessing therapy, which is sometimes called EMDR. That's another kind of intervention that can be used. And these are just some examples.

So also to throw out there, there are a lot of different adaptations of other trauma-focused interventions. So for example, I had the pleasure of doing a training called Real life Heroes, which was a narrative-based therapy intervention specifically meant for latency age kids. So, younger kids who might not have the same verbal abilities as teenagers or adults, and helping them sort of think through and make sense of what happened in their lives.

There's also a number of interventions that can be delivered in a group format. So, cognitive processing therapy is, which I had just mentioned, can be done in an individual setting or a group-based setting. There's also an intervention called Skills Training in Affective and Interpersonal Regulation, or STAIR, which recently came out of the VA. And there's now adaptations that are coming out for use of that particular intervention in teenagers and young adults. In addition, some people might benefit from medication or medication interventions that can target some of the symptoms that we often see in individuals who experienced trauma, such as anxiety or depression.

While there's no set medication that can treat PTSD specifically, there are certain medications such as prazosin that can be used, for example, to treat nightmares, which are frequently seen as a symptom in individuals who've experienced trauma.

Host: So, you described a lot of treatments, which is encouraging that there are many options out there. I want to differentiate these a bit, and I guess I would start by asking you about PTSD versus other posttraumatic problems that can occur for individuals who've experienced traumatic events.

And let's start with PTSD. I'm familiar with various modalities that involve some kind of re-experiencing exposure. And that can be quite difficult for patients, obviously, because that's the thing they're trying to avoid as part of PTSD. So, I wanted to hear more about the different choices for PTSD, how the exposure plays a role, and what other options are available just within that one diagnosis.

Dr. Jessica Hartman: Sure. So as you mentioned, exposure can be oftentimes a critical piece of what occurs in trauma-focused treatment to help reduce the experiences of anxiety or hypervigilance or heightened sensitivity that can often come, and the general sort of disruptiveness that can come when an individual is exposed to reminders of their trauma, be it something in their day to day life or flashbacks.

And I think really a lot of the work that happens in advance of doing these exposures is focused on other very foundational elements. So, things like teaching relaxation and helping the individual identify coping skills that help them to either stay calm or feel calmer if they're feeling dysregulated affective regulation and learning how to manage intense or strong emotions. And cognitive coping and learning maybe how to challenge or question thoughts that might not be realistic or might not be helpful are often foundational skills that we see being done in the individual sessions before we even get to the point of thinking about an exposure. There are some interventions that focus a little bit less on exposure-based formatting.

One other thing that I think is important to mention about exposures is they're done in a very planned and graduated manner, and they're done very collaboratively. So for example, we're never going to force someone into an exposure they don't feel ready for or capable of handling yet. And of course, in some cases, exposures might not be indicated if potentially that could cause more damage or create a situation that's unsafe.

I think it's also important to note that there are some interventions that have shifted away from doing trauma narratives or focusing quite as much on exposure-based interventions. So one example of this is CPT, which was one of the interventions I mentioned earlier, does now have an adaptation that does not include a trauma narrative as part of its sort of core components. And there are also some psychodynamic interventions that are currently being studied primarily in adult populations that are showing significant improvement in trauma-related symptoms without necessarily having this more behavioral or exposure-based focus. And I think there's a lot of exciting research going on in the field that we will be able to dive into in the coming months or years to learn about new ways of intervening and helping meet people's needs in treatment in a way that feels meaningful to them.

Host: It is really exciting hearing about a lot of the research that's going on, lots of new approaches in psychotherapy, as well as pharmacologically with things like psilocybin or MDMA. Can you speak to some of the new developments on that front?

Dr. Jessica Hartman: Sure. So yes, we are seeing some exciting research emerging in these areas, including the uses of MDMA in treating PTSD or the use of microdosing with psilocybin. Right now, of course, there are also some ethical and legal implications for this kind of treatment that I think have yet to be sorted out on a larger scale level. However, there are studies that are happening that are primarily adult-focused and are looking at if these types of interventions can be useful in helping treat PTSD or symptoms of PTSD or trauma-based symptoms more largely.

There's also a question right now in the field if ketamine, which has in the past been found to be helpful for treatment-resistant depression, can be a helpful treatment for PTSD or related symptoms or be used to help augment treatment for people who are struggling with these symptoms, which can sometimes be very challenging to overcome.

Host: And it's important to add here that when we're talking about MDMA or psilocybin, these studies are in conjunction with psychotherapy, isn't that correct?

Dr. Jessica Hartman: Yes. In many cases, these are interventions that are happening with a therapist present and guiding somebody through whatever their specific protocol is. They vary a little bit study to study in terms of helping address. I think the theory, and this is not 100 percent my area of expertise, but the theory is that the MDMA or use of something like psilocybin can help with the reprocessing and how we sort of make sense of that memory in our minds, because we know that memory is one of those core areas that's implicated in terms of the experience and re-experience of traumatic events.

Host: In our first episode with Dr. Richard Friedman, he actually talked about psychedelics and how there's increased neuroplasticity, which perhaps there's a receptivity that's going on with these substances that then could allow psychotherapy to be more effective in the short term, even than it would be without. A lot more to learn there for sure.

I want to go back to everything but PTSD. So when you're looking at posttraumatic effects for people who need psychological support, are you using the same treatments? Are you using other interventions?

Dr. Jessica Hartman: So, I think that can vary a little bit clinician by clinician and also might vary client by client depending on the needs that they're coming in with and they're looking to address in treatment. So, if you have an individual who's experienced a traumatic event and is having perhaps some and not all of the symptoms of PTSD and it's really causing significant distress and interference, yes, a trauma-based intervention can still be incredibly effective and helpful, and in many ways, really helping that person understand that that experience was real and very valid, regardless of whether or not they sort of check the boxes of a certain diagnosis.

Host: So, there's lots of ways in which people impacted by trauma can get help. Do you have advice on what steps individuals who've struggled with trauma can take to help themselves in their everyday lives or what someone who's let's say a loved one or friend of that person can do to help them after they've been impacted by a traumatic event?

Dr. Jessica Hartman: I think one of the things that can be really helpful for individuals to think about are adaptive coping mechanisms that help them feel better. And you might find the answer to this and the things that help you feel better, even just when you're stressed after a long day at work or stress at school, if you're on the younger side, and that's a really good clue of where you can start.

So, aside from all of the sort of therapeutic or pharmacological interventions, there are a lot of other things that can be helpful, and it can include things like engaging in a hobby you really enjoy or some other kind of pleasant activity, be it sports or doing puzzles or any baking or cooking, talking to someone for support or spending time with others. Connecting with others can be incredibly helpful. The use of mindfulness has so many applications and it can be incredibly helpful here. So engaging in mindfulness, even if it's just carving out a couple of moments during the day to take some deep breaths, focus on perhaps a meal you're eating, really noticing the sensations of the texture of the food or what it tastes like. Getting adequate sleep and having a routine around sleep can be really important. Sleep can also be extremely disrupted when you experience trauma, so to the best you can, having a routine. And relatedly, having adequate nutrition and exercising regularly can also be really helpful. Having schedules and sticking with them can also sort of give you a sense of routine, or in some cases, normalcy, if your routine's been incredibly disrupted by an event. And you can also look for support in other ways. So in some cases, individuals will seek out support through something like a support group. Participating in a support group where you can be around others who've had a similar experience can also provide a lot of validation and help people feel less alone.

One other sort of insight to share, I think it's really important for people to figure out what's right for you, because not everything on this list is going to work for everyone. And I'll sort of share an experience from my life, which was when I had first started working, I had joined the gym and they happened to offer yoga classes. And I went in and I was in the classes and doing the deep breathing and attempting to get into all of the poses. And I often found that my mind was wandering and I was thinking, "Am I doing this pose correctly?" And I would often leave the class just as stressed, if not more so than when I entered. And the stress may have been different and yet I didn't find that I was feeling better.

And one day I decided, "I think I'm going to skip the class and I'm going to try one of the machines instead." And I hopped on a treadmill, and I started running. And I hate running! So, I sort of forced myself through it, and yet what I found, with the music on and sort of feeling the sensation of my foot connecting with the ground or the treadmill. I left and I was like a different person. And I felt so much better after that. And no matter the stress I'm dealing with, I always find that if I can go for a run, even if it's just for a few minutes, I always leave it feeling a little bit better than when I started.

And that was a really important lesson for me to learn, that yoga wasn't the way to go. I needed something with a little bit more physical activity and that was what worked for me. So, figure out what works for you. And if you can take that and go forward with that, that's going to serve you in a lot of different domains in your life, hopefully.

Host: So, those are some great steps that individuals can take that you just reviewed. I'm wondering about loved ones or friends who want to help someone.

Dr. Jessica Hartman: So, I think there's a few different things people can do. The big one is really to show up and be supportive. And again, this might look different depending on what the situation is. I think sometimes there's a natural instinct when somebody has gone through something really challenging to try and figure out, "How can I fix this? How can I make this better? How can I solve this problem." And I don't know that that's always helpful. And in dyadic work, we sometimes talk about things like, "Are you listening to listen? Are you listening to solve the problem?" Because those can be two very different things.

When someone is struggling or has experienced a really challenging event in their life, you might be in a position where you can lean in with support, and yet there's not a lot that you're going to be able to say or do that's going to make it better. And sometimes just being willing to sit with somebody in those dark moments and connecting with those experiences that you've had where maybe you felt a little bit in the dark, and maybe actually or metaphorically just holding their hand and sitting with them and saying "I know what it means to be here and to struggle and I'm here for you" can be incredibly valuable.

And I think again, depending on your relationship, there might be opportunity to do some of what I was describing earlier about what individuals can do. So maybe if you have a friend who loves to read, you can think about reading a book together and talking about it. Or if you love to cook, doing a potluck and different people can come. So again, we want to think about things that can bring people together and build those connections.

And I think it's really helpful for people also to realize there's a model in the grief world that posits the notion grief shrinks over time, and that's sometimes how people conceptually think about, "Oh, it's going to lessen a little bit more each and every day." And actually, what we see with grief, and oftentimes with trauma, is it actually doesn't shrink at all. It stays exactly the same, and yet we as individuals or as loved ones who are supporting an individual who's experienced that kind of event can help them learn to grow around that, and how can we fill their lives, or our own lives, with other meaningful experiences and meaningful interactions that help us grow around the grief.

Host: Thank you. And it's so clear that the social connectedness is a key component for helping people through this. I mean, the isolation that can come as part of PTSD or other posttraumatic effects is something that sounds like it actually is part of it, but also makes it worse, and to help attenuate that by connecting is one important intervention that friends can help with, that individuals themselves can seek out. So, that's very important advice.

Dr. Jessica Hartman: And in some cases, people who've experienced traumatic events will experience the phenomenon that we know as post-traumatic growth where your self-perception or self-awareness, your self-confidence, your appreciation of life, or feeling as though you have new possibilities, that can also happen as well. And that's sort of not to silver line, but that is sort of a path forward out of grief. And if you are trying to support someone who's experienced grief, if that's sort of the journey they're on, joining them on that journey can be incredibly meaningful.

Host: And what about sharing with them that you're observing growth?

Dr. Jessica Hartman: Absolutely. I mean, I think we all love to hear positive things about ourselves, really in any capacity.

Host: Well, the last thing I want to ask you, a little more concrete, is are there specific resources that people can turn to online that you might recommend to people who want to learn more about trauma or the effects of trauma?

Dr. Jessica Hartman: There are some wonderful resources that are out there. They're a little bit sort of specific based on who they're targeting. I personally am a huge fan of the National Child Traumatic Stress Network, which has a number of amazing resources for both providers and for families. Many of them are geared specifically towards children and adolescents. However, I think many of the things that are taught in those resources are equally applicable to adult populations in terms of how to provide support, and their website is nctsn.org. SAMHSA, which is one of the organizations we talked about in part one, the Substance Abuse and Mental Health Services Administration, also has some excellent resources on trauma-informed care, and those can be found at samhsa.gov, S-A-M-H-S-A.gov. I'll also add the VA, the federal VA network system, has some very good resources. Those tend to be a little bit more focused on PTSD specifically and they tend to be very adult-focused as that's primarily who the VA is working with and treating. But it can be a wealth of information if that is the information you are seeking. And their website is ptsd.va.gov.

Host: Jess, thank you so much. I learned a lot speaking with you today and when we recorded our first episode on this topic. Trauma is ubiquitous. It's constant in our world and you've helped provide a clear understanding of what it is and importantly what we can do to help people build resilience and thrive in the face of adversity.

Your work supporting children who've survived trauma is truly inspiring. And in the aftermath of tragedy, you're someone who's still instilling hope. Thank you for doing that work and thank you so much for joining me today and on our prior episode on this topic.

Dr. Jessica Hartman: Thank you.

Host: And thank you to all who listened to this episode of On The Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, Apple Podcasts, and iHeart Radio. If you like what you heard today, tell your friends, give us a rating and subscribe so you can stay up to date with all of our latest episodes and fantastic guests. We'll be back soon with yet another episode of On The Mind.

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