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Wise Counsel Interview Transcript: An Interview with Victoria Lemle Beckner, Ph.D. on Treatments for Post-Traumatic Stress Disorder (PTSD)

David Van Nuys, Ph.D.
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Dr. Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

On today's show we'll be talking with Dr. Victoria Lemle Beckner, co-author of the book, "Conquering Post-Traumatic Stress Disorder." Dr. Beckner is a licensed psychologist with 11 years of clinical and research experience in the areas of stress, anxiety disorders and depression. She received her doctorate in clinical psychology from the University of Texas at Austin and was then awarded a post-doc research fellowship in the Department of Psychiatry at the University of California at San Francisco, where she is now a professor.

Dr. Beckner has provided PTSD treatment to military veterans at the San Francisco VA Medical Center and civilians through UCSF and her private practice, The San Francisco Group for Evidence Based Psycho-Therapy. Her research investigates how the stress neuro-endocrine system affects memory and physical illness as well as testing new treatments for acute trauma, combat PTSD and depression.

She recently completed a three-year grant funded study on how a stress management treatment may reduce the negative effects of stress on brain lesions and symptoms in multiple sclerosis. Dr. Beckner teaches courses and workshops on psychiatric disorders, vicarious trauma, the role of stress in illness and cognitive behavioral therapy for anxiety disorders.

She was also invited to co-teach a course at the University of Rwanda in 2006 on multi-cultural treatment approaches to trauma in the context of genocide. "Conquering Post-Traumatic Stress Disorder" is her first book.

Now, here's the interview.

Dr. Dr. Beckner, welcome to Wise Counsel.

Dr. Beckner: It's great to be here. Thank you.

Dr. Van Nuys: Before we get into your book, how about telling us something about your background.

Dr. Beckner: All right, I actually was born and raised in Southern California. Originally when I went to school and college, I majored in philosophy and history. I didn't actually start off in psychology. When I graduated I ended up going to Washington D.C. and I worked there for seven years actually in the field of public affairs and legislative affairs. It wasn't until I was about 30 that I actually decided that I wanted to go back to school and study psychology.

Dr. Van Nuys: Now, what was drawing you to psychology at that point in your life?

Dr. Beckner: I actually loved my work in D.C. I did a lot of media and lobbying for NASA and the space company, but it wasn't really tapping into my passion. I was very interested in what makes people tick and I was really interested in studying both scientifically and working with people clinically.

I ended up going back to school at night while I was working. [laughing]

Dr. Van Nuys: Oh boy!

Dr. Beckner: Yeah, and got an undergraduate major in psychology and then applied to grad school.

Dr. Van Nuys: And where was that that you applied?

Dr. Beckner: I went to the University of Texas at Austin and their clinical psychology program. There I studied anxiety disorders, the treatment of anxiety and also got very interested and started to do research in the nature of stress. Stress hormones and how neuroendocrine changes and stress affect memory.

Anxiety and stress have been a theme throughout my psychology career. Then I went on to do my internship at the San Francisco VA Medical Center. That's when I became very clinically interested in Post-Traumatic Stress Disorder.

Dr. Van Nuys: OK. Quite a progression actually in that direction, I guess. So your book is about PTSD and most people are probably familiar with the term PTSD but maybe we should have you define it anyway for our audience, just in case.

Dr. Beckner: OK. Let me give a slightly longer answer to that because I think it is helpful to understand how PTSD symptoms develop.

Dr. Van Nuys: OK.

Dr. Beckner: When somebody experiences a traumatic event such as a car accident or combat or assault or a disaster, their brain and body is flooded with stress hormones. This interferes with an area of the brain called the hippocampus that consolidates memory. It also causes changes in the brain that enhances the anxiety alarm system that people have.

So the memory of the event gets very fragmented and emotionally charged. This is why one set of symptoms people get is re-experiencing symptoms of the trauma: flashbacks, nightmares, intrusive memories and thoughts. Meanwhile, their body is on active danger alert constantly after the trauma. So they are experiencing continuous symptoms of anxiety, irritability, feeling on edge, jumpy, and also having trouble sleeping. We call these physiological arousal symptoms.

Then, what has also happened is when the person experienced the trauma, all of the cues and situations associated with the event get conditioned in the brain so that the brain now associates those cues and situations with danger. Then whenever the person encounters those, they have an automatic anxiety response. This causes people to start to avoid anything associated with the trauma. This can be quite debilitating. People with PTSD quite often, their whole world starts to shrink. They stop going to social events. They stop going out. Sometimes they can end up being house-bound.

There is also a set of symptoms called emotional numbing where, I think because of all the very intense emotions, their mind and brain kind of shut down and become very flat and numb. They have difficulty experiencing pleasure in the things they used to enjoy. All of these symptoms actually start to interfere with people's relationships. Their relationships are often hurt in PTSD as well.

Dr. Van Nuys: Well, that is very complete. [laughs]

Dr. Beckner: [laughs]

Dr. Van Nuys: ... a very complete definition rundown. I was going to ask how a person might know whether or not they were suffering from PTSD but I think you gave us lots of clues there: flashbacks, trouble sleeping, depression, difficulty in relationships. What else? Am I leaving anything out?

Dr. Beckner: Numbing, emotional numbing.

Dr. Van Nuys: Oh, yes.

Dr. Beckner: And really if they find they are avoiding things, I think that is also a strong clue.

Dr. Van Nuys: Yes. I was intrigued when you mentioned the stress hormones and their impact on the hippocampus. I guess that is a result of a couple of other interviews I've done where the hippocampus seems to have played an important role for people who have been studying memory loss due to either Alzheimer's or normal aging. Different areas of the hippocampus seem to be implicated as involved somewhere in that chain of events. So I was wondering if the hippocampus, in terms of memory, if somehow that is implicated in flashbacks?

Dr. Beckner: You know, that is an interesting question. I mean we do know that during a trauma the hippocampus gets flooded with cortisol and is kind of over-stimulated and that is why you've got this disruption in memory. How memories are actually stored in the brain and how they get triggered is much more complicated.

Dr. Van Nuys: Sure, sure.

Dr. Beckner: It just involves all areas of the brain. I'm not sure if people know exactly some cue, some association with the trauma starts to trip that neural networked memory. That's where you end up getting the flashbacks and the intrusive memories. But what are all the brain regions involved in that? It's going to include frontal lobe and many other regions as well.

Dr. Van Nuys: OK. You just sparked a little hypothesis [laughs] for me.

Dr. Beckner: [laughs]

Dr. Van Nuys: I had to run that by you. Now you wrote this book with a co-author, Dr. John Arden.

Dr. Beckner: Yes, that's right.

Dr. Van Nuys: How did you two come to write the book? What was the sort of driving motivation and the intended audience?

Dr. Beckner: John has interest and experience in many different kinds of disorders and he is an author. He ended up coming to me and talking to me where I had a little bit more of the specific PTSD experience. So my interest in the book was, I see now many different kinds of trauma in my private practice and also through my research at UCSF. So not just combat trauma but assault, rape, childhood abuse. I also do some disaster work.

One of the things I've been amazed by is we have some very effective treatments for PTSD and yet, the majority of people who have PTSD never seek treatment. Maybe only 10%. Because a lot of the information we have and a lot of the skills that we teach people could be conveyed in a book, my interest was this is a way of helping many more people than just those who come in for therapy.

I think John and I were both interested in really expanding home mental health care to people who've experience with trauma.

Dr. Van Nuys: There are a lot of books out there about PTSD. But I guess the unique thing about your book is really is that it seems to be directed toward self-help. That's what you're saying, right?

Dr. Beckner: Yes, so it is. The book is designed as a self-help book for people who have had trauma and it does provide information. It has different sections that teach different skills: skills for reducing anxiety and depression, and panic attacks. Skills for overcoming avoidance, relationship skills and also actually strategies for working through the trauma memory itself.

There are other self-help books out there. Some of the books are geared for a specific trauma: like combat trauma or rape. So ours is more general. It's for any type of trauma. But what I think is unique about the book is that we really do include some of the techniques called "exposure techniques" that help people really confront both the trauma memory and the situations that they are afraid of and avoiding.

I think self-help books tend to shy away from that. So we do that. We've also integrated post-traumatic growth strategies because after someone has gone through such a profound experience such as a trauma, their life has really been altered and their sense of self and meaning in the world. Although, at first, I think this is quite devastating, there is an opportunity there for people to tap into their resiliency and really find ways of growing from the experience.

Dr. Van Nuys: Yes, I was struck by that. The last chapter of your book talks about using trauma as an opportunity to grow. I think most people might find that idea a little surprising. That something so awful could be turned into a growth opportunity.

Dr. Beckner: Yes. What's interesting is that research has really shown that people often find the silver lining after really terrifying or frightening events. Like there have been studies of people who, for example, experienced a diagnosis of cancer and are facing mortality. What you find is that some people are really able to take that life and death situation and really make them look at what is important in their life; what do they want to do in their life. It kind of inspires a carpe diem, seize the day, mentality.

Dr. Van Nuys: Great. Great. Now you drew on several therapeutic modalities in writing the book: cognitive behavioral therapy, positive psychology and mindfulness. Let's talk about each of these and what they have to contribute. Why don't you start with cognitive behavioral therapy and say how that is woven into the book.

Dr. Beckner: OK. The cognitive behavioral techniques in the book have actually been carefully researched and are really effective techniques for all of the anxiety disorders but certainly for PTSD. The cognitive techniques are helping people to really identify what are some of the core beliefs that have been challenged by the trauma and to have people really look at those beliefs and challenge them and try to work through them.

Dr. Van Nuys: Would an example of a belief like that be, "Nothing bad will every happen to me"?

Dr. Beckner: Right. That's true. I think most people go through life and one of their core beliefs is that bad things happen to other people. Or bad things happen to bad people and good things happen to good people. Then they go through a traumatic experience and all of a sudden the world feels like it has lost a sense of justice and morality. How could this happen to me?

There are many different ways to start to work through that change. That's a change that happens, a common change. Also, people can feel like the world is no longer a safe place. Or if they have experienced something like rape, that other people can't be trusted.

There are many ways in which people's fundamental beliefs can get shifted. So there are different ways of working through those beliefs. You can write about them. You can challenge them by really... one of the things you find is that those beliefs often end up being very extreme and self-protective, which makes sense after a trauma, but it's not a good way to go forward in your life.

Depression is also very much affected by the way people think. As the depression, which often occurs with PTSD, you see people seeing everything as the glass is half empty; making interpretations that the future is going to be hopeless. That people don't care about them. So, again, the cognitive techniques really try to work through some of those automatic thoughts and interpretations.

Dr. Van Nuys: Yes.

Dr. Beckner: So those are the cognitive techniques. The behavior techniques involve having people go out and behaviorally confront the situations they've been avoiding. For example, if they're avoiding social situations, it would be to encourage people to set up a program where they go out once a week and meet with friends, or do something social. It's geared toward getting people to change their behavior, even if they don't feel like it.

Behavioral therapy is the idea that you don't wait until you feel better to change your behavior. You change your behavior, and then you feel better. [laughs] Those are some of the cognitive behavioral techniques. I was just going to add that they're also just communication techniques for working through problems that come up in relationships, and also just ways of managing anger, particularly in relationships.

Dr. Van Nuys: OK. And, of course, positive psychology... I was interested to see that that was one of the threads of influence in there, positive psychology being relatively new on the scene, but having gotten a lot of attention and notice among psychologists. Tell us about that part of the book.

Dr. Beckner: I think John and I really liked taking some of the work from positive psychology, such as Marty Seligman's emphasis on trying to identify your signature strengths and values as a way of trying to live your life in a meaningful way. We thought that was such a beautiful fit with what you see in research on post-traumatic growth. Often, people do start to really realize what their strengths and values are, after they have started to recover from the trauma.

We wanted to bring in some of those exercises and techniques for identifying what are my strengths, what are my values, what do I really want to do with my life, how do I want to spend my time, using this really difficult, traumatic experience as a wake-up call for tapping into what is really important in one's life.

Dr. Van Nuys: Mindfulness is another concept that seems to making its way, more and more, into psychology and psychotherapy. Tell us about its role in your approach.

Dr. Beckner: Mindfulness is really a very simple technique for, in a way, learning to tolerate a person's emotions or thoughts. A way of being mindful is, when a person experiences intense anxiety, for example, to really just notice the feeling, describe the feeling to themselves, notice the danger thoughts that they're having.

In that awareness, there's a way that people can detach, just a little bit, from what they're thinking and feeling. Another name for this is called affect tolerance or emotion tolerance.

This is really what meditation is about. Meditation and mindfulness is about not trying to stop the feeling, not trying to make the feeling or thoughts go away, but just noticing what you're thinking and feeling, as if you were a third party looking in on yourself.

This is actually a really powerful way for people to learn that they can tolerate their feelings. It gives a little bit of space for them to choose how they want to respond and cope, instead of just feeling like the sense of anxiety is overwhelming, they can't stand it, and then they just act out.

Dr. Van Nuys: I take it this is stuff that you do in your private practice and in the work that you do at UCSF, and you find it to be effective.

Dr. Beckner: Yeah, and I will say that I think a lot what people do in cognitive behavioral therapy is very similar to mindfulness, in the sense that it's all about teaching people to be willing to fit with their feeling, rather than run away from their feeling.

Some of these techniques have different terms and different approaches. Maybe it's exposure in one, and it's mindfulness in another, and it's affect tolerance in another, but I think, fundamentally, it's just teaching people how to be able to ride through their thoughts and feelings.

Dr. Van Nuys: Yes. It looks to me like East and West have been coming together, in terms of some of the ideas coming out of cognitive behavioral therapy, and then techniques like mindfulness coming out of the Eastern tradition of meditation. It seems like the two worlds are coming together in some interesting ways.

Dr. Beckner: Yeah, and I think they integrate really well.

Dr. Van Nuys: Since we're talking about alternative things that are getting integrated in, there are two other approaches that I wonder, have you've heard anything about them, have you tried them, and what's your impression? The first is EMDR, which is Eye Movement Desensitization Reprocessing.

I believe that that was actually developed to deal with PTSD, if I recall. Is that something you've used, or looked into, discarded, or are exploring? Where are you in relation to EMDR?

Dr. Beckner: Well, I do know a fair amount about EMDR. I will give you my impression.

First of all, there've been research studies to show that EMDR is an effective treatment for trauma. There have also been research studies that indicate that what's effective about EMDR is, essentially, the exposure of component to the trauma memory which is the same as what is done in cognitive behavioral therapy for PTSD.

In other words, I think there's evidence to suggest that what makes EMDR effective is actually what it has in common with, say, any of the other exposure techniques. Cognitive processing therapy is another one that uses writing to do exposure to the memory.

I don't think there's any evidence to support the expert theoretical explanation for why it works, which is the bilateral stimulation for a left-right brain. Until there's evidence to support their theory, I'm going to go with the fact that it's effective because it's essentially exposure therapy.

Dr. Van Nuys: OK, then you might feel similarly about another one that's perhaps a little further out, I don't know if you've heard of it, it's called EFT, or Emotional Freedom Technique. Have you heard of that?

Dr. Beckner: It sounds familiar, but I don't know anything about it.

Dr. Van Nuys: It's similar to EMDR, in as much as a person is asked to re-imagine, in successive approximations, I believe, the traumatic experience. While they're doing that, at first, they report their subjective level of distress. Then they engage in a sort of tapping of acupuncture points, as they're reliving the experience, and then they report their level of subjective distress again.

Reportedly, and I've interviewed a number of adherent two or three treatments, sometimes a single treatment, that they see dramatic results.

Dr. Beckner: Well, I'm a girl who likes to see the evidence, the data. [laughs]

Dr. Van Nuys: I don't think there is any science on this yet that I've heard of.

Dr. Beckner: Well I would encourage the people who are proponents to go out and do some therapy trials just to measure its effectiveness.

Dr. Van Nuys: Yeah.

Dr. Beckner: Yeah. Maybe it's helpful to actually talk about why having people talk through the trauma memory is so important.

Dr. Van Nuys: Sure.

Dr. Beckner: I'm calling that, that's a form of exposure called imaginal exposure where the person confronts the trauma memory by either talking through the memory or writing about it or imagining it. And the reason why this is so important is that remember that the trauma memory is really disorganized and has this very intense emotional connection in the brain.

When people walk through the experience and tell their story and in prolonged exposure, they do it over and over again in a very structured, ritualized way. It's as if they are slowly reorganizing the memory in the brain and slowly working through the emotion and the meaning and habituating or desensitizing themselves to the experience.

So a lot happens when they confront the memory and work through it. And that's why John and I felt it was so important to have some exercises in which people actually work through the trauma memory in the book.

Dr. Van Nuys: Yes. How can a person know whether or not the self-help approach has really done it for them, or will do it?

Dr. Beckner: That's a hard question. [laughs] I think that for those who are reluctant to go to therapy but want to learn something about trauma and how they can start to heal themselves, a book is a great way to start and there is a lot that can be helpful. But I don't think a book is a substitute for therapy. So my hope is that people would maybe work through the book but then perhaps take that extra step and seek out treatment for their PTSD because there's a lot that happens in therapy that you could never convey in a book.

The other thing I would say is for those that are in therapy, I think, the book can be a great adjunct to therapy because it is concrete. It's got the exercises in there. It's got all the information. But I really don't think people can cure themselves of trauma by just working through a book alone.

Dr. Van Nuys: OK. Well that's an interesting perspective from the author of such a book [laughs], but it sounds wise to me. You know, you mentioned the returning veterans from Iraq and Afghanistan. What's happening with them? I've read that PTSD rates are through the roof. Are there resources here at home to deal with them?

Dr. Beckner: Yeah, so of the returning Iraq and Afghanistan vets, over a quarter of them are coming back with some type of mental illness and the majority of those is PTSD. So this is a huge number for returning veterans. What I will say is that, I think, the military has been doing a surprisingly good job in these wars; of really trying to educate soldiers about what some of the symptoms are and encouraging them to get into the VA system once they come home.

Now, the VA has actually been very aggressive in increasing funding for mental health services. And I know there has been some negative press at some of the VA sites, but I can tell you, just from having worked at the San Francisco VA Medical Center, that the vets there get exceptional care. There are very well-developed programs, integrated care and focusing not only on combat trauma but also military sexual trauma. I actually think that there are many powerful resources for the returning veterans.

Dr. Van Nuys: Well, that's good to hear. As we wind down, are there any last thoughts you would like to share with our audience?

Dr. Beckner: Gosh, last thoughts. Well, I guess I want to just return for just a moment to the theme of, if someone out there has experienced a trauma, not everybody develops PTSD, but I do think that there usually is some kind of fallout from the experience. That often people do experience some symptoms or changes in the way they feel about themselves or their relationships.

I would just encourage anybody who has been through some kind of really terrifying life-changing event to go out there and find information, seek therapy, read the books that are out there and also really try to take advantage of the experience as an opportunity to find new ways of growing in their lives.

Dr. Van Nuys: Well, that's a good wrap up. Dr. Dr. Beckner Lemle Beckner, thanks so much for being my guest today on "Wise Counsel."

Dr. Beckner: Thank you, David. It was a pleasure.


Dr. Van Nuys: I hope you found this interview with Dr. Victoria Lemle Beckner to be informative. If you or someone you know is suffering from PTSD, her book "Conquering Post-Traumatic Stress Disorder" might be a good place to start dealing with the issue. The book's subtitle is, "The Newest Techniques for Overcoming Symptoms, Regaining Hope and Getting Your Life Back." In fact, it will give you an authoritative overview of PTSD treatment along with a lot of very practical self-help exercises.

You've been listening to "Wise Counsel" a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. Dr. David Van Nuys and you've been listening to "Wise Counsel."