Latest / The Trauma Therapist / Episode 745: Getting Unstuck from PTSD with Patricia Resick, PhD, ABPP

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Episode 745: Getting Unstuck from PTSD with Patricia Resick, PhD, ABPP · The Trauma Therapist

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Are welcome back to the Trauma Therapist Podcast. My name is Gaming Person.
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My mission is to help trauma therapist be their incredible cells, to be human,
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to be real, not just a clinician. I'm a big believer in
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who we are is more important than what we know, and this requires cultivating
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authenticity, genuineness, and vulnerability, and that requires intention. Can learn more
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about my courses and workshops by going to the Trauma Therapist project dot com.
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That's the Trauma Therapist Project dot com. Let's get started to five or three,
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two and one. Our folks, welcome back to the podcast. I
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am at thrilled. How is my guess today? Doctor Patricia Musick, doctor
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Music, welcome to the podcast. Thank you. They're welcome so. Doctor
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Music is a professor of psychiatry and behavioral Sciences at Duke University Medical School.
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Doctor Music began developing and testing cognitive processing therapy CBT in nineteen eighty eight at
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the University of Missouri Saint Louis, where she founded the Center for Trauma Recovery
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and was an endowed professor. CPT is considered first line therapy for PTSD in
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the United States and several other countries. The cpt Treatment Manual has been translated
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into twelve languages. Doctor Music served as president the International Society for Traumatic Stress
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Studies and the Association for Behavioral and Cognitive Therapies. She is a recipient of
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lifetime Achievement awards from is STSS, ABCT and Division fifty six of the American
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Psychological Association, among other honors. Doctor Music is the author of the new
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book Getting Unstuck from PTSD Using Cognitive Processing Therapy to Guide your Recovery. Doctor
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Music, an honor to have you on here. Thank you so much for
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being here. Thank you. Before you're welcome. So before we get going,
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share with our listeners where you're from originally and where you are currently.
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I'm sorry. Where I was originally? Yeah? Where you're from originally?
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Oh, I grew up in Ohio. Okay, And I'm guessing you're at
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Duke. I'm a duke. You can tell from my background, I can
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tell from your background. Yeah, Okay, awesome. So let's start,
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if we may, How the heck did you get on this journey? Yeah?
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People often asked that I was on internship in at the Medical University of
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South Carolina and the BA and a couple of the people that I became friends
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with. Um, we're in the process of setting up one of the first
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rape crisis centers in the country. This is in the midset in nineteen seventies,
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and they asked if I wanted to be a rape crisis counselor, and
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I said, sure, what's that because there was no such thing, And
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so I got the experience. I'm getting up in the middle of the night
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and sitting in the waiting in the waiting rooms of the emergency rooms with rape
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victims while I was doing my internship. And it just happened that at that
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time, the National Center for Mental Health, National Institute for Mental Health decided
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to a lot three million dollars, which was a lot of money back then,
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to study rape. And so my supervisor, Dean Kilpatrick, suggested,
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maybe we should try looking at the effects of rape, because everybody was saying,
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like, what's the big deal, Like why is that a problem?
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Isn't that just sex? And so we wanted to show him, no,
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it wasn't just sex. We were looking at anxiety and fear and that kind
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of stuff and doing a longitudinal study and then starting to do a bit of
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treatment. And then I went back to finish my degree at the Diversity of
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Georgia, and another person, Karen Calhoun, asked me if I also wanted
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to work on a grant looking at depression. So we submitted two grand applications
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and they both got funded. So in the meantime, I had taken a
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job at the University of South Dakota and so I was flying back and forth
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for the next four years between the University of South Dakota and either Charleston or
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Atlanta to work on these longitudinal studies. And that's what got my got me
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interested. I started out in child and doing parent training and stuff like that.
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But like everything we learned was absolutely unknown at the time, so everything
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was publishable, everything was of interest. Let me pose if I may for
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a second here. So you said, when you were an intern, you
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kind of thrown into this experience or dove into it, I mean, and
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that's pretty intense. I mean, just to be jump sitting in the middle
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of the night with people who what was that like for you? It was
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it was very strange because people, I mean, first of all, they
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made them wait for hours, and it's like, you know, if you
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bleed, you lead in a newspaper world. Same thing in an emergency room.
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So a rape victim is sitting there like maybe crying, but maybe in
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shock. And so very often they got put in last place, and most
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er physicians back then and nurses did not even know how to do a rape
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exam. They were often treated very badly. People would say horrible things.
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I remember one man running in looking for his wife and say, what did
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they do to me? What did they do to you? So, I
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mean, it really let me know that people knew nothing about the topic,
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and that fired me up, first of all to find out what are the
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effects and the second of all, how do we treat it? And this
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is before there was a PTSD. PTSD wasn't determined to be a diagnosis until
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nineteen eighty and I started in the mid seventies working on the problem. So,
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as I said, we were right at the very beginning of trying to
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figure out, you know, how this trauma affected women. Wow, fascinating.
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So how do things unfold for you such that? How did you conceive
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of putting together a treatment for this? Well, we didn't tried it.
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A couple of other treatments. We tried something that was called stress inoculation treatment
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which Mike and Baum had developed, which is kind of a problem solving kind
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of treatment, and and then I got when I got to the University of
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Missouri Saint Louis, I looked at that and compared it to kind of just
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a general psychotherapy, and it just wasn't be with the results. I also
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didn't think of it as an anxiety disorder anymore because I had worked with enough
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rape victims who said I didn't think he was going to kill me, but
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because it was my husband or my boyfriend or whatever. But I was so
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humiliated, I was so betrayed by that person, and so they were feeling
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shame and guilt and all sorts of other emotions that were not fear and anxiety.
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So I'm like some other people who were looking at treatments for PTSD as
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an anxiety disorder. I went the other way and was studying the work of
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Aaron Beck and his cognitive therapy for depression, and so that's how I ended
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up developing CPT because he wasn't working with PTSD. But I thought this fits
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better having people look at their thoughts and having them look at their no matter
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what emotion they're feeling, whether it's fear, anxiety, anger, sadness,
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guilt, shame, across the board. We can work to a cognitive therapy
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with them and you change their thoughts, you change their feelings. And then
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it were so, how did you begin working with patients? If you can
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maybe share some early examples of what you did, well, we were we
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were studying rape victims when I was in Charleston, still on internship, and
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as I said, doing the rape crisis counseling. I didn't actually start seeing
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patients until I got to the University of South Dakota, and I saw a
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few up there, low population. So when I was looking for another job,
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looking to move, I actually looked for a job that had a high
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crime rate. So I ended up moving to Saint Louis. In any city
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of two million or more would have been done the trick, but they happened
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to have an opening job opening at the University of Missouri Saint Louis that year,
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and that's when I really started doing the treatment work. We had a
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clinic, it was a clinical psychology doctoral program, and they had a clinic
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there and and that's when I started actually doing the treatment and experimenting with like
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what actually works, like measuring what you're doing, which is be part of
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my training. So what did you do specifically? Well, I mean early
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on, as I said, we were looking at problem solving skills, we
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were looking at some other kinds of just general psychotherapy kind of stuff, and
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I wasn't happy with the results. Say there was no difference between them,
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and I wasn't happy. But that's when I started moving over into the cognitive
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therapy. And at that time, Aaron Book's book on Treating Depression was a
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man was one of the first manuals, but it was too vague for me.
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I wanted something that was going to say session one, do this,
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session two three, do this, and make it really systematic so that anybody
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could pick up the book and if you knew how to do cognitive behavioral therapy,
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you could just pick it up and do the therapy. Now, obviously
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there's a lot of people who haven't been trained, and that's we have a
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whole training program now where we do workshops and and do consultation, you know,
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twenty sessions of consultation while they're you know, to make sure that they're
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doing it correctly, with good fidelity and things like that but um, but
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by the time I got my first big grant to study that, and I
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was comparing it to prolonged exposure which had come out about the same time that
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said in the FOS and she was doing exposure therapy and I was doing a
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cognitive therapy. But that that was nineteen ninety four. By the time I
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got that grant um and UM, I had already seen I had already done
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pilot work on eighty four women on CPT before I ever got that grant UM,
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so I had a lot behind me. And then I had graduate students
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doing it as well, and we really thought it worked. And then we're
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able to convince and I h to give us the money to do this controlled
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trial. Early on, when you thought that maybe you should systemize this session
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one session two, for example, can you walk us through what the early
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stages of your ideas of okay, session one should be X, Y,
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and Z. What did that look like? Well, as I said,
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you know, I had a lot of pilot cases first. I mean usually
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you start with education, and so the question is why do you have PTSC
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Because lots of people don't get PTSD after a trauma happens to them. Sometimes
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they already had PTSD and this just made it worse. Sometimes there's something about
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the trauma itself that they can't get passed. And the concept that I had
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was, there's get something getting is stuck, getting them stuck in their natural
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recovery. And so we started thinking about the thoughts that they're thinking, the
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conclusions that they've come to as being what we called stuck points. And so
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a stuck point would be this doesn't fit in with my prayer beliefs. You
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know, if I think that the world is supposed to be just and good
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things happen to good people and bad things happen to bad people, then this
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horrible thing happens to me. Well, I'm a good person. This doesn't
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fit and so now you've got conflict. So we were seeing seeing it as
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kind of a failure to accommodate to this event. It's too big and it
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doesn't fit your old beliefs. On the other hand, sometimes people had a
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lifetime of abuse from the time they were little. They were being physically,
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sexually, and emotionally abused. This event might fit right in, and they
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might not have new PTSD, but they might have already had PTSD. Wow,
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so these I mean the way what you're articulating now is is huge.
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I mean right, I mean just the way you're saying it. It sounds
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we've all heard that now, but at that point in time, I mean
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to recognize that hold on here, this you're getting stuck. This is conflicting
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with your your belief systems. I mean this, these are really major discoveries.
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I'm curious, um, Patricia for you, you know, the thought
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that some of these people, uh were experiencing sexual abuse and rape and realizing
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that, you know, how could this, how how could someone do this
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to me? How the feeling of betrayal and shame? What was that like
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for you personally witnessing that? Being in that room. Well, I mean
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I learned very quickly you can't tell somebody it isn't your fault, um and
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and so then um, listening to their stories, I also had learned very
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quickly that you can't start feeling their feelings for them. You know, you
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have to stand back and think about how did they get stuck? What's interfered
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with their recovery? Because I was thinking of it. There's other disorders that
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people develop over time, but PTSD is something we think of is something blocked
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their recovery, because there's a lot of people who do recover over a period
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of month. So what blocked it, what's gotten in the way. So
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I was specifically looking for places they got stuck in their recovery, and that
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most often it's a thought, it's my fault, I should have done something
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different. If only I had done this, it wouldn't have happened. So
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they keep going back and trying to redo the event and make it come out
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differently, or making some kind of an assumption that is something about them personally
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that had happened to them. But I also discovered very early on you just
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can't convince somebody of that thought that they've been living with for a long time.
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So that's when we developed doing socratic questioning, meaning you ask them questions
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that are going to lead them to a different conclusion. What is specifically what
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would that look like for someone? Well if somebody says, uh, let's
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start with the rape picked and let's say somebody says, it's all my fault
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that had happened, and I say, okay, so what did you do?
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Well, I would I had a drink that night, Okay, so
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how did that drink allow that person to rape you, or cause that person
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to rape you. Did you ever have drinks and didn't get raped? Do
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you know of anybody else has been raped and hadn't had a drink? You
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know, so you can you can ask all sorts of questions. What was
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your intention when you went out that night? Well, I was out with
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friends. I mean we were just there having a good time. It was
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Friday evening and so on and so on. So we kind of walk them
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through the reasoning that I'm thinking in my head that they're not because they're focused
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on I had a drink, so therefore it's my fault. And did you
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Well, obviously you did, but I was going to say, did you
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find that successful? It seems like such a challenging thing to do because a
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lot, like you said, you can't change someone's thoughts right just by telling
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them it's not your fault. I'm just curious how that it unfolded such that
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you were like, Okay, this is this is working, this is making
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sense. Well, that's why that's why we ended up developing these these worksheets
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that teach them the skills of learning to explore and examine their own thinking.
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So The first thing you have to do is help them understand the difference between
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an event and a thought. You know, just because you think something doesn't
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make it true. The event is the rape. Now what's your thought about
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it? You know, what you're even saying to yourself? And when you
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say that, how do you feel? So then we had to help them
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think about different kinds of emotions and emotions and if you change a thought,
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your feeling might change, So we use neutral examples, etc. Then we
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move on to teaching them how to We start doing the Socratic questioning and dialogue
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with them, and then we start giving them. We start handing the therapy
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over to them very ly quickly, giving them a list of questions to ask
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themselves about a specific step point. You know, they'll come up with a
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step point log At we have them do an impact statement and where they write
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down not what happened, but why do you think it happened? And then
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how do you think it's affected you in terms of safety and trust and power
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and control, esteem? And I'm going to see some of these topics that
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are like how's it affected your life now and into the future. So we
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write all that stuff down and then we start exploring going through those thought by
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thoughts. Yeah, wow, I mean it sounds like in a sense,
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you just by the very nature of what you were doing, it sounds like
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you were kind of disrupting their whole thought process, right, just getting in
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there, but in the first place and being willing to discuss what happened,
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and you know itself was kind of a disruptor in a sense, right,
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and getting them to recognize that just because they think something doesn't mean necessarily mean
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I think something. So they'll say it happened because and I'll say, so
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your thought is And as soon as I say that, I'm not saying that's
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the fact, I'm saying that's your thought, right, Well, that already
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starts to get to loosen things up a little bit. And when you say
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that, how do you feel? Right, let's just pause here for a
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second to thank our sponsors. All right, we are back. Was the
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word trauma even in the vernacular at that point. By the time I developed
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cpt it was PTSD. Was the diagnosis of PTSD came out in nineteen eighty
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so, and I started really working on developing CPTN eighty eight. So PTSD
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did exist, and so people were talking about post traumatic stress disorder, then
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yes, definitely, but there weren't many treatments at that point. Let me
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just remind everyone I'm speaking with doctor Patricia Musick. Her new book is called
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Getting Unstuck from PTSD Using Cognitive Processing Therapy to Guide Your Recovery. So tell
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us about this new book. Why did you write it, who's it for,
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etc. We had a treatment in, well, we've had a treatment
19:45
manufact we're just in the last stages this week of revising the treatment manual and
19:49
sending it in. But there are so many people who can't get good therapy,
19:56
can't afford therapy, or I mean, it's them out a lot,
20:00
especially since the pandemic that people people's waiting lists are a mile long, and
20:07
then to get people who are actually trained in CPT is particularly difficult. We
20:11
have a website and people can look it up, but they contact people and
20:14
they can't get treatment. And I've actually had people buy the manual and say,
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but this looks like a therapist manual. Was a yeah, it is
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a therapist manual. So I had suggested with a couple of colleagues that maybe
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we could write a self help manual so that somebody could pick it up and
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walk through all those steps. Now we don't call it session one, session
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two, session three, because if they're not doing this weekly, they're doing
20:41
it maybe daily. So it's more it's thinking more in terms of units of
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or skills that they you know, this process they go through. So we
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teach them how to you know, some background stuff and how to assess their
20:56
own PTSD and then how to do that ac sheet the events, thoughts and
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feelings, and then going from there questions to ask themselves and so on and
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so on and coming up with an alternative thought is more balanced. So the
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whole idea behind the new book is that it is a self help book for
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people who can't or are hesitant to go to a therapist, and so we're
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hoping that it'll reach more people who aren't going to get good treatment otherwise.
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When you look back over at the arc of your experience to those far you
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know, compared to when you started, when you were first launched into sitting
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with women who'd experienced rape in the middle of the night, what are some
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of the things you think about? What we know, what we as a
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culture know about sexual assault and rape and trauma and PTSD and how we're viewing
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it. I wish I wish I could say we've come farther than we have.
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I mean, I've been working in this field for forty years and I
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don't think the rates have changed at all. So I was hoping that people
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would start realizing that's not a good thing to do to somebody, whether it's
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doing it to a man, a woman and a boy, or our girl
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or anyone. I think as a society we are more understanding of somebody when
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it happens to them, But I think we still have a tendency as a
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society to expect people to just get over it. Or conversely, sometimes people
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think, oh PTSD, that means you're gonna have it forever and you will
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never get over it. And we're finding that most people can get over except
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for military who tend to take a bit longer, and that we could get
22:52
into that for other reasons. But most civilians and even I heard recently first
23:00
sponders, they can get over it in seven and nine sessions. They don't
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even need a whole twelve sessions of therapy. It can be easily treated even
23:07
with people who have a lot of other symptoms who have had a lot of
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trauma in their lives, because once you change you're thinking about your worst trauma,
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then it all starts to tumble down and it changes you're the way you
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think. The analogy I sometimes will use with clients or what I'm doing training
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is that they've been going down this path like going through a jungle, and
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they've been saying it so many times, and they keep saying it over and
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over and over, and it becomes the only path and it leads them right
23:41
into the muck or they're feeling horrible about themselves, And I describe the CPT
23:47
is giving them the machete the tools to make a new path that's going to
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take them to a whole different place, and that eventually that other path is
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going to get overgrown and not be the path they automatically take. So I
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think once you've got this either way of thinking, it then affects the way
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you think about lots of things, normal events in your life, other traumas
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that may happen to you. We've done long term follow ups five to ten
24:15
years later and people don't relapse. Wow. Yeah, So I mean that's
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that's the fun thing about it. Sounds like it would be horrible to work
24:26
with trauma or PTSD, but it isn't. It's for a therapist. Is
24:30
so gratifying because people get better and then they stay better and it changes their
24:36
life. Sometimes it saves their life. Now you kind of compared treatment for
24:44
an EMT versus someone who's experienced rape. Is that discrepancy in terms of the
24:51
length of treatment and length of recovery? Does that have to do with the
24:55
fact that obviously sexual assault and rape, is it an interpersonal trauma? And
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now I said, I said, first responders also responds. Okay, Military
25:04
people tend to not recover as well. But I think some of that has
25:08
to do with their training. They're trained to go into war and they're trained
25:15
to be hyper vigilant, which means when they get it back to civilization,
25:18
they're not retrained to relax a little bit and just be normally cautious. They're
25:23
still hyper vigilant. They're taught things like, you are responsible for your men,
25:30
so if anything happens to them, you're responsible. You know, it's
25:34
a built in guilt maker. Or never leave someone behind. What if they
25:41
had to leave someone hot behind? What if they couldn't save them? So
25:45
there's this training, and it makes sense that they're trained this way. But
25:51
unless they've got a lot of cognitive flexibility, it's hard for them to come
25:56
back to civilization and be in the civilian world and just give up those beliefs.
26:02
Um. So you know, I think that's one of the things that's
26:06
showing up now is that they need more and they and they need probably more
26:11
sessions, and they probably need maybe permission to give up some of those beliefs.
26:15
I wish the military would untrain people when they let them. Um,
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well, what are the difference between the difference trauma. It's like, well,
26:23
we talk about interpersonal trauma. Is well, I think the content of
26:30
the thoughts are different. The therapy doesn't have to be different. But but
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when we do the therapy with somebody, everybody's unique. They come in with
26:38
their own history, they come in with their own um, how they were
26:42
raised by their parents, um, the kind of friends or they have or
26:48
don't have, their trauma experience. You know, how how people reacted when
26:52
the trauma happened to them, whether they told people or they isolated them.
26:56
And so everybody's unique anyway. UM, But there's some there's some events that
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are. I mean with the military, also, there's more likely to be
27:06
head injury, and so we have to keep adding mind just like if we're
27:11
working with battered women, there's very likely to be some head injury, and
27:15
they may need more sessions or they need to do more repetitions of worksheets to
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kind of get it in there. Traumatic loss is another situation where people may
27:27
have PTSD and they feel guilty that they should have saved somebody or you know,
27:32
the suicide of a loved one, that they'll they feel very a lot
27:36
of guilt and shame that they somehow didn't know or somehow couldn't save somebody.
27:41
So and so I think sometimes with first responders, it's a matter of helping
27:45
them walk through that they really literally couldn't save that person, and it's kind
27:49
of wishful thinking on their parts that they could have saved everybody. So interpersonal
27:56
traumas are are are unique in that they've got somebody probably that well maybe they
28:03
knew who did it to them, but maybe not. I had one rape
28:07
victim who explained to me, when somebody you know turns on you and attacks
28:11
you this way, they become a stranger. Oh, that makes sense.
28:17
So maybe all rapes are stranger raps. So, if I'm hearing you correctly,
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are you saying that there's not necessarily a difference in the length it takes
28:29
for someone to be treated, no matter it doesn't matter what type of trauma
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it is. Well, we're trying to figure that out still. I mean,
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I think we take military I'll, you know, active duty or veterans
28:41
a little bit longer than it takes civilians, and that's the way it seems
28:45
to be. But even when we compared military and civilian women, it isn't
28:52
a gender thing. The civilian women recovered more rapidly than the veteran women.
29:00
They have gotten that military training. So I think in some cases we're still
29:07
trying to figure out what is it. I mean, did they go into
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the military for a particular reason, did they get trained in a certain way.
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There's variables, there's so many variables, and it's going to it takes
29:18
a while to get that kind of untangled. But the nice thing about CPT
29:22
is that it's based on like what they're thinking. What everybody has their own
29:30
set of thoughts, their own set of ideas about like what caused it and
29:36
what they should have done, and whether they're feeling scared, or whether they're
29:40
feeling angry, or whether they're feeling shame or whatever it happens to be.
29:44
We just based it on the individual. So it's a very Although it's a
29:49
structured therapy, it's it's tailored for every single person. As we kind of
29:56
wind down here, can you give us a thumbnail? You did it a
30:02
little bit, But of what CPT is well, CPT is a cognitive therapy,
30:08
which means we focus on what they're saying to themselves about. We start
30:12
with their worst trauma and then move on to other traumas they've had. Most
30:15
people who come to therapy have had multiple traumas one trauma. Typically people who
30:22
don't go to therapy they go to therapy when they've had many. So we
30:25
try to incorporate whatever traumas they've had and help them explore through the questions that
30:33
we ask. It doesn't make sense to say what you've been saying because they've
30:37
got stuck to keep saying the same thing over and over again, like a
30:40
broken record. I probably shouldn't say record. Some of your younger viewers won't
30:45
know what that is. But or a dog chasing its tail. I mean,
30:51
they don't get anywhere, but they keep going back over and ruminating about
30:53
how they should have done things different, And we try to break up that
30:56
cycle by asking them this very specific question. Is not narrow thinking, but
31:02
let's open up the picture. What else was happening? How old were you,
31:04
how small were you? Who else was there? How far away was
31:07
that person you thought you could have saved? Was it even possible? You
31:14
know? So we're asking a lot of those kind of questions and helping them
31:17
rethink what actually happened at the time. And then once they start thinking about
31:22
maybe I'm wrong in how I'm assessing this, then maybe that has implications for
31:27
why I don't have to distrust everyone else, Because if the original event didn't
31:33
have anything to do about trust, why am I distrusting all these other people,
31:38
etc. Or if I think it was because I had bad judgment,
31:41
does that mean I always have bad judgment? So finally, can you share
31:48
an early clinical error and what you learn from that? Well, I've already
31:52
mentioned a couple of those early clinical errors was trying to convince people that it
31:56
wasn't their fault, and they'd look at you like you're crazy. You don't
32:00
know you weren't there, and I think being too impatient. We have it
32:08
laid out as a twelfth session therapy, but when we do it as a
32:10
variable length, it's anything from four or five sessions all the way up to
32:15
twenty some sessions, And it depends on how quickly they can change their own
32:20
flexibility about things, how much they need to practice. When we're working,
32:22
as I said, with people with traumatic brain injury, or even the elderly
32:28
who don't have the memories and they've been thinking the same way for sixty years,
32:34
it may just take them longer to kind of change the way they think.
32:38
They're not going to Younger people are going to have that aha moment and
32:43
they go oh okay and they change their thinking. Somebody who's been thinking that
32:46
way much longer is going to have more trouble and it'll take a lot more
32:52
practice. Right, So, being impatient and thinking they should get the first
32:57
time you work on a thought that they should change it. The name of
33:00
the book is called Getting Unstuck from PTSD Using Cognitive Processing Therapy to guide your
33:07
recovery. Doctor musick, Where can people get this book? First off?
33:12
And then what's the best way for people to get in contact with you.
33:15
Okay. First of all, they can either get it from the publisher,
33:19
Guildford Press, or they can look it up through Amazon or any any other
33:24
bookseller. UM wherever books are sold, wherever books are sold, and contacting
33:34
me is UM Patricia dot Esik at Duke dot edu. Okay, email there
33:39
and our website if they're interested in just learning more about it is CPT for
33:45
PTSD all small letters and Stuck together dot com. Okay. So this is
33:53
I mean, like I said, an honor to have you on here,
33:58
UM, to talk to you, who created this major modality in the treatment
34:05
of trauma. What's next for you? Retirement? We're rewriting the main therapist
34:15
manual. It's been after a while. We've we've learned a lot since then.
34:19
We're simplifying worksheets, etc. We're making a match the self help manual.
34:24
I've got another textbook I'm working on and they're writing up lots of research
34:29
findings. So well, awesome, inspiring, pleasure having you on here.
34:37
I want to thank you so much for taking the time. Thank you all
34:39
right, take you care, Bye bye.