There are several types of anxiety disorders that a person may experience, which may cause any level of emotional discomfort and, in some cases, may become an obstacle to accomplishing daily tasks necessary for living. For example, the fear of being trapped in a public space where help may not be available, characteristic of Agoraphobia, may cause someone to become social isolated over time as a result of avoiding public spaces. The Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5) lists seven other anxiety disorders, including:

• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobia
• Social Anxiety Disorder
• Panic Disorder
• Generalized Anxiety Disorder
• Substance/Medication-induced Anxiety Disorder

Some of these disorders may be more recognizable to you than others such as Generalized Anxiety Disorder characterized by uncontrollable worry about a number of situations and Panic disorder, which involves surges of intense emotion often accompanied by body sensations like heart palpitations, dizziness, and sweating. While each of the disorders listed above have trait symptoms unique to the specific disorder, they are all unified by intense worry and extreme focus on anxiety-related thoughts. For example, people suffering from anxiety may have rigid thoughts about the future that they can’t seem to get out of their heads such as: “What if I have a serious medical condition and die?” “What if I’m rejected?” “I’m a complete failure!” As such, first-line treatment for any anxiety disorder necessarily involves addressing these types of distorted thoughts with tools and techniques from Cognitive Behavioral Therapy (CBT), a heavily researched type of talk therapy proven useful in working with these types of thinking errors. A psychotherapist trained in CBT will help you work through your anxiety by teaching you how to identify and challenge thoughts that typically trigger feelings of anxiety. CBT sessions are designed to help you develop the skills to successfully build resilience to acute anxiety in about 12-14 sessions.  Depending upon the severity of your anxiety symptoms, your CBT therapist may also recommend that you schedule a medication evaluation by a medical doctor to assess whether adding a psychotropic medication to your treatment plan may further help feel better!

I am a trained CBT-trained psychotherapist and having been using it to help hundreds of people successfully work through their anxiety over the 22 years I have been practicing in the field of behavioral health. Please feel free to call or e-mail me if you have any questions about CBT and how we might work together to resolve your anxiety-related problems.

Written by Tony Madril, LCSW, BCD

Post-traumatic stress disorder or PTSD is a mental health condition that is triggered by experiencing or witnessing a terrifying event that involved serious injury, sexual violence, death or threatened death. Symptoms may occur immediately and may include any or all of the following: problems sleeping, flashbacks, nightmares, severe anxiety, avoidance of reminders of the trauma, distressing body sensations, and uncontrollable thoughts about the event. Moreover,

Symptoms of PTSD fall into the following four categories:

1. Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.
2. Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.
3. Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.
4. Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping

If you have experienced these symptoms over a month or longer and notice that they have interfered with your regular day-to-day activities, you might consider seeing your primary care physician or a mental health professional who can help you determine if you qualify for the disorder and discuss how you might benefit from PTSD treatment.

If you believe that you might have PTSD, it may be helpful to know that there are several treatments that research has found to be effective in helping people work through their symptoms. Cognitive Processing Therapy or CPT is one such evidence-based treatment. CPT is a twelve-session, manualized treatment protocol which focuses on helping a traumatized person modify negative cognitions related to themes of safety, trust, power and control, and esteem and intimacy. CPT has one of the largest bodies of evidence to support its effectiveness than any other treatments for PTSD. Other research-based PTSD treatments are Eye Movement Desensitization and Reprocessing (EMDR) therapy, Prolonged Exposure (PE) and medication.

If you would like more information about PTSD treatment, you may contact me by telephone, (323) 315-2598, or by e-mail: tony@tonymadriltherapy.com

Exercising Choice & Past Trauma

Saying “no” when you would typically say “yes”; replying to a friend or coworker: “let me think about it” instead of immediately deciding; leaving a stressful situation for a few minutes to find your center. These are all examples of choices you can make to promote your well-being when feeling cornered by circumstance. Choosing to place your needs first can have profoundly positive effects upon your life; it has the power to loosen old patterns that don’t serve you anymore.

What is more, if you have experienced any type of trauma in your lifetime, choosing to do something to take care of yourself in a moment when you are feeling “stuck,” can counteract the feeling of being “frozen” in your body. Feeling as though you cannot or should not move in a moment of distress is often a by-product of having experienced trauma and is very much related to the automatic “fight, flight, freeze” response you are probably familiar with. Making practical choices to take care of you when you think you cannot, can help to replace the constant replay button of trauma with a renewed sense of self-confidence and safety.

What choices can you make today to take better care of you?

Recognizing and accepting that, as a member of the human race we are inherently imperfect, and will, therefore, always be subject to the occasional “bad day” is perhaps one of the most practical things we can do to increase our sense of psychological wellbeing and resilience to life’s difficulties. It is easy (and sometimes oddly satisfying) to berate ourselves for falling short of the expectations we hold for ourselves; however, doing so may only intensify and prolong our emotional distress when we’ve made a mistake or somehow failed to fulfill our personal standards of accomplishment.

What if we could make another choice? Instead of harshly judging ourselves after a moment of vulnerability, what if we could do or say something to soothe our distress in the very moments of our crisis? In fact, the second element of self-compassion is recognizing that suffering and personal inadequacy is part of the shared human experience – something that we all go through—not just “me.” As such, exercising self-compassion offers us a pathway out of our suffering by helping us remember that everyone has bad days, everyone makes mistakes…we are all unmistakably imperfect.

Exercising self-compassion also means connecting with people who support us in the very moments we need them the most. For example, calling caring friend or supportive family member and sharing the details of our crisis can help to break the sense of isolation we may feel as a result of judging ourselves; moreover, the other person’s unconditional acceptance of us “warts and all” makes it difficult to keep blaming ourselves. Like preventing an arrow from being shot and wounding us after we’ve already been hit, exercising self-compassion after we’ve recognized how we’ve harshly judged ourselves can help ease our suffering on those bad days when we need some extra help to regain our balance. What do you think?

Clinical practice guidelines recommend psychological treatment interventions to target PTSD in veterans (International Society for Traumatic Stress Studies, 2009; The management of post-traumatic stress Working Group, 2004, 2010), and there a number of evidence-based treatments that have emerged from clinical trials and are recommended by agencies commissioned to meet the behavioral health needs of veterans experiencing combat and other trauma-related forms of distress. For example, in 2010, the U.S. Department of Veteran Affairs (DOVA) and the Department of Defense (DoD) assembled a workgroup to establish practice guidelines for treating PTSD in veterans and found exposure-based therapies, cognitive-based therapies, stress inoculation training, and Eye Movement Desensitization and Reprocessing (EMDR) to be “A-level” treatments for veterans with PTSD (The management of post-traumatic stress Working Group, 2010). Moreover, the DOVA website specifically names Cognitive Processing Therapy (CPT), Prolonged Exposure (PE) and Eye Movement Desensitization and Reprocessing (EMDR) as “effective treatments for PTSD” (https://www.ptsd.va.gov/public/treatment/therapy-med/index.asp), and veterans have seemingly done well by receiving these types of recommended psychotherapies throughout the years (Kitchner et al., 2012) –or have they? A 2012 Congressional Budget Office study suggests that 78% of veterans with PTSD who received care from the Veteran’s Health Administration continue engagement with evidence-based trauma therapies, like PE and CPT, after four years of receiving an initial diagnosis of PTSD (Congress of United States, 2012). What is more, the National Center for PTSD reports that some veterans may never be free of trauma-related symptoms (https://www.ptsd.va.gov/public/index.asp).
These facts are troubling and highlight the need for a critical examination of first-line PTSD treatments for veterans. In other words, veterans who are receiving the “best we have” in trauma treatment and continue to require help for their symptoms begs a number of serious questions such as: What, if anything, is missing from first-line PTSD treatments for veterans? Is the individualistic nature of evidence-based treatments for PTSD limiting recovery and the achievement of resilience? Can the individualistic nature of first-line PTSD therapies be augmented to meet a broader spectrum of veterans’ psychosocial needs? If so, how?
In an attempt to answer these questions, the author will argue that there are a number of core treatment elements missing from available “gold standard” interventions for veterans with PTSD; elements that, if included within existing evidence-based models of PTSD treatment, could have a positive effect upon treatment outcomes for veterans regardless of which evidence-based trauma treatment they receive.
The author posits that one such missing element is the basic consideration of the relationship between veterans and their families by those offering trauma treatment. Although scant, there are enough empirical studies to argue the importance of considering the relationship between veterans and their families when deciding which therapeutic elements to include within evidence-based PTSD treatments for this esteemed population.
That said, what follows is a description of the structure of a family therapy session the author has designed to demonstrate how family therapy can become an essential component of evidence-based PTSD treatment for veterans like CPT:

Session 1
INTRODUCTION TO FAMILY THERAPY FOR PTSD
Summary of Session Content

Goals:
• The family will understand the treatment rationale for pairing family therapy with the veteran’s individual EBP sessions.
• The family will gain a basic understanding of the symptoms of PTSD.
• The family will gain a fundamental understanding of the ways in which PTSD symptoms can, and often do, become expressed within family relationships.
• Family members will learn the ways in which the family functions as a social system.
• The family will experience a general sense of ease and growing sense of trust with the family therapist.

Key Intervention:
1. Psychoeducation. One of the keys to the success of this first family session is the therapist’s ability to effectively explain the concept of systems theory. In practical terms, the family therapist’s task here is to aptly explain how the family operates as an “emotional whole” despite each of its individual members seemingly acting on their own accord. How is information this relevant to the family’s recovery from PTSD? If the veteran and his or her family members can gain a basic understanding of how all social systems operate–including family systems–then family members will, at the least, be better equipped to consider the important role each person plays in the maintenance and resolution of the presenting family problems, including those associated with PTSD. You might say that this initial conversation with the family will set the foundation for the entire course of family therapy for PTSD.
Moreover, to instill a clear understanding of how family systems function, the family therapist may use the following visual aid during the session to physically demonstrate how all family members may react to changes in another family member when they become clinically affected by PTSD:

Figure 1
Child’s Mobile

During the therapist’s explanation of the family as a system, he or she may use an actual child’s mobile and physically strike the lowest hanging mobile piece (in this case the large star) to demonstrate how, not only the large star, but the rest of the mobile pieces (the crescent moon, Pluto-shaped planet, etc.) are propelled off of their normal axis by the sheer force of the therapist’s hand. “Like the child’s mobile struck by an outside force, every family member is affected when one of its members experiences PTSD symptoms,” the therapist might say.

If more appropriate, the therapist might rather use the metaphor of a flying formation of military jets; for instance, if the family does not have any children or if the therapist believes that the image of the child’s mobile may, in any way, appear infantilizing to the veteran and/or his or her family.

“One jet pilot’s slightest move off course affects the course of the other pilots,” the therapist might alternatively say.

Framing the Family Solution
At the end of the first family session, the therapist would encapsulate the content of what was communicated throughout the hour by
making a summarizing statement that continues to frame the solution as a collective effort:

During the next few weeks in family therapy, we will be considering the problem of PTSD to be everyone’s; therefore, the focus of therapy will be working with everyone to examine your ways of communicating with one another; to help you become more aware of the ways in which each person may be contributing to the family’s problem with PTSD and working to improve it. As your family therapist, I will be offering you the opportunity to learn new skills to use in your family that you may find helpful. I will also be asking you to help me find new ways to help you help one another. Everyone will be asked to improve your relationship with yourself and with every family member. The benefit of doing this work may be that you feel more connected to members of your family; perhaps because you understand them just a little bit more. Whatever the outcome of our work together, I am confident that the time we spend together will be worthwhile!

There are many theoretical reasons to expect that adding family therapy to existing evidence-based PTSD treatments for veterans will significantly reduce PTSD symptoms while meeting the comprehensive mental health needs of veterans. The premise that mental health symptoms can be socially improved is firmly based upon decades of family therapy practice as well as research with veterans who have seen improvements in PTSD by engaging in systems-based PTSD treatments similar to family therapy.
In summary, the author proposes that existing evidence-based PTSD treatments for veterans is insufficient to treat the complex nature of veterans who are actively engaged in relationships with their families and romantic partners. Existing evidence-based PTSD treatments do nothing to address these transactional relationships, which may be prolonging or complicating recovery from trauma symptoms. And, while treatment of family and couples has been identified as a potential means of enhancing the effectiveness of treatment for veterans (Sherman et al., 2005), there are currently no evidence-based PTSD for veterans that provide opportunities for partners and family members to fundamentally contribute to symptom improvements; therefore, the author would argue that family therapy should be included in trauma treatment for veterans unless there it is contraindicated due to risk of physical or psychological harm.

References available upon request.

Written by Tony Madril, LCSW, BCD

What is self-compassion? Self-compassion is a mindful way of recognizing when you are experiencing a moment of emotional or physical suffering (or both) and choosing to behave kindly toward yourself in response to the pain. For example, self-compassion can be useful when you notice the temptation to pursue someone whom you know to be emotionally withdrawn or simply not a good fit with your idea of a suitable friend or romantic partner. When you notice such an urge, you might invite yourself to cultivate self-compassion in that very moment by taking the following actions:

1. Recognize the urge to repeat an old and unhelpful pattern and consider that the urge may simply be your mind’s way of communicating to you that you have an unmet need that requires your attention.
2. Identify the need or emotion beneath the urge to repeat the self-defeating pattern. For example, if you find yourself drawn to pursue an unavailable person, you might notice that you are feeling lonely and in need of reconnecting with friends or family.
3. Validate and reassure the part of yourself that wants to “fall back” into an old way of being by quietly saying to yourself something like: “Sweetheart, I sense that you are feeling lonely and need to be comforted…I’m here for you now, and want you to know that I am going to take good care of you!” You might even place your hand upon your heart while saying these words if you feel comfortable doing so.

You might try taking these three steps over the next few weeks to see if it makes a difference in how you relate to yourself through the challenging moments of your life.

Written by Tony Madril

Feeling mixed emotions? That may not be such a bad thing. Studies show that having the right mix of positive and negative emotions can actually lead to positive gains such as psychological growth, and an increase in physical health and creativity. Researchers suggest that the “right mix” of emotions to achieve these benefits is three to one; that is, three positives to one negative emotion at any one time. While this type of neurochemical “brew” can spontaneously occur as a byproduct of our unconscious reactions to life’s circumstances, it can also be consciously cultivated by the choices we make related to our emotions.

For instance, noticing when I am happy and, then, purposefully focusing my attention onto the physical manifestations of happiness in my body is one way of building more positivity into my life. In fact, recent studies in neuroscience suggest that the very act of “pausing” and “attending to” body sensations, like warmth around the heart, during a moment of fulfillment may prolong the joyous experience; even focusing on the comforting body sensation for 5 or 10 seconds may be enough to boost positivity and increase the likelihood of reaching a better balance of emotions. If you are interested in putting this information into practice, you are invited to mentally repeat the words investigate and allow the next time you are experiencing a positive emotion and see what happens for you.

Written by Tony Madril

Mindful awareness increases our ability to be aware our thoughts, feelings, and body sensations. It helps us notice subtle changes in our moment-to-moment experience; for example, when we have been emotionally triggered by something within our environment or within ourselves. Perhaps we may become aware of a sudden increase in heart rate, an increase in muscle tension in our shoulders, or a subtle disturbance in our field of vision. This is important because noticing unexpected changes within our mind and body, however subtle, can alert us that to the fact that there may be something in need of our immediate attention.

When this happens, we may benefit from pausing and asking ourselves: “Have I been triggered?” or “What might be triggering me?” Noticing that you have been triggered, you might additionally ponder: “What can I do, now, to best take care of myself?”

Instead of avoiding the emotional discomfort of having been triggered by trying to escape, we might be better served by addressing the source of the problem; by deep breathing; calling a friend, or by scheduling an appointment to see our therapist. Mindfulness used in this way can enhance our ability to make better decisions about self-care over time, and prevent unnecessary health problems in our lives.

Written by Tony Madril