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Julian D. Ford, Ph.D., ABPP - Guest
Julian D. Ford, PhD, ABPP, a clinical psychologist, is Professor of Psychiatry at the University of Connecticut School of Medicine, where he is Director of the Center for Trauma Recovery and Juvenile Justice and the Center for the Treatment of Developmental Trauma Disorders. He has served as President of the International Society for Traumatic Stress Studies, is a Fellow of the American Psychological Association, and is Associate Editor of the Journal of Trauma and Dissociation and European Journal of Psychotraumatology. Dr. Ford has published more than 250 articles and book chapters. He is coeditor of Treating Complex Traumatic Stress Disorders in Adults, Second Edition, and Treating Complex Traumatic Stress Disorders in Children and Adolescents, and coauthor of Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach. His research focuses on developmental trauma disorder and the Trauma Affect Regulation: Guide for Education and Therapy (TARGET) therapeutic intervention. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D: (00:25)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training and evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on-demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our lifespan centers, Center for Children, and Center for Adolescents, where all the therapists are working systemically, our Center for Couples, where all the therapists are using emotionally focused couples therapy, and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our Center for ADHD and Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D: (01:32)
At the Institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com, and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 nonprofit, so all donations are tax deductible. Today, I'll be speaking with Julian Ford, a clinical psychologist who is a professor of psychiatry at the University of Connecticut School of Medicine, where he is the director of the Center for Trauma Recovery and Juvenile Justice, and the Center for the Treatment of Developmental Trauma Disorders.
Keith Sutton, Psy.D: (02:33)
He has served as president of the International Society for Traumatic Stress Studies, and is a fellow of the American Psychological Association and the International Society for Traumatic Stress Studies, is editor of the Journal of Trauma and Dissociation, and associate editor of the Journal of Racial and Ethnic Health Disparities. Julian has published more than 350 articles and book chapters. He is author of Crisis in the Psychotherapy Session: Transforming Critical Moments into Turning Points, co-editor of Treating Complex Traumatic Stress Disorders in Adults, Second Edition, and Treating Complex Traumatic Stress Disorders in Children and Adolescents, and co-author of Treatment of Complex Trauma: A Sequenced Relationship-Based Approach. His research focuses on developmental trauma disorder and the Trauma Affect Regulation: Guide for Education and Therapy Therapeutic Intervention called Target. Let's listen to the interview.
Hi, Julian. Welcome.
Julian Ford, PhD: (03:28)
Thank you, Keith. Great to talk with you.
Keith Sutton, Psy.D: (03:31)
Yeah, thanks so much for taking the time today. So, I ended up learning about your work. I was doing some research on the differential diagnosis with ADHD and complex PTSD, which then led me to some of the work that you did, an article in 2000 on developmental trauma disorder and coming up as ADHD or oppositional and some of the overlaps in the symptomatology, and then reached out to you and got to learn more about your work and your target model, which sounds really great, a cognitive behavioral therapy model that adds on an aspect of affect regulation that sometimes isn't there, in other models based on neurobiology, which is wonderful. So I want to hear about all these things, but first, I always like to find out, you know, people's journey.
Keith Sutton, Psy.D: (04:20)
How did you get to doing what you're doing? What kind of led to the evolution of your thinking?
Julian Ford, PhD: (04:25)
Well, I've gone through many phases in my career, starting when I was still an undergraduate in college and I worked for a year and a half as a line staff person at a state psychiatric facility. I think that's where I learned so much from the men and women who were the patients there, as well as my colleague. But it took another 20 years or so before I actually realized the impact that trauma has had on so many of the clients that I've seen and that I've had the privilege of seeing since then. So it really wasn't until I started working as a psychologist in the Department of Veterans Affairs in Oregon, back in 1990, so more than 30 years ago, on a PTSD treatment unit.
Julian Ford, PhD: (05:20)
And so I had, for about 10 years, I was able to work with military veterans, men and women who experienced PTSD. And then in that time, I also was able to work at a, a program called the National Center for PTSD, which is actually part of the Department of Veterans Affairs, but it extends well beyond veterans, and at Dartmouth. And there was a wonderful child psychiatry group there who were doing some really unique research on trauma history with kids who were diagnosed with, attention deficit hyperactivity disorder, ADHD, and oppositional defiant disorder, ODD. And that's where that 2000 paper came out. It basically was from a case series of kids who had those diagnoses, but when we inquired more carefully about their trauma histories, many who were diagnosed with oppositional defiant disorder in particular, somewhat also with ADHD, many of them had very significant trauma history.
Julian Ford, PhD: (06:22)
Many of them had PTSD symptoms that had just never really been identified. And then that led me to go on as I came to Connecticut back almost 10 years later, and have been here since then, and working with adults now, and then again, back with teenagers more recently. But the, the common thread I've seen Keith, is that so many kids and adults who are experiencing some of the most difficult symptoms of emotional and behavioral disorders - not only have trauma histories, I think we pretty much know that, but they're also, they're experiencing many of the symptoms of traumatic stress. And often are not identified as having PTSD bebecause it may not be absolutely clear that they have specific memories of traumatic events. Many cases, they may not remember details of or even remember events at all.
Julian Ford, PhD: (07:25)
And these are not repressed memories, they're just memories that are not accessible, just as many of our memories are not accessible as we go through life. And so it just became clear to me that--and this actually goes back to my work with the VA too, because in working with the men with chronic PTSD, it was very clear to me that many of them had difficulties that went well beyond PTSD, and that's right when a group led by Bessel van der Kolk and Susan Roth and David Pelkovitz, and Judith Herman were talking about complex PTSD for the first time. And so I actually did, I made a priority for a program that I was directing then with, which was an inpatient residential program for chronic PTSD. We assessed complex PTSD and we found that a substantial proportion of the men who were in this program not only had PTSD, but they had really significant difficulties with emotion regulation, with their bodies just being completely kind of detached from their awareness in many respects, dissociation of other kinds as well.
Julian Ford, PhD: (08:46)
And again, these are people who are incredibly resilient. . They, , I could never cope as well as they do. I wouldn't be functioning if I'd been through even a fraction of what they've been through. But they also had really significant difficulties that went well beyond PTSD. So I then joined with this group that has been working on the idea that there is a complex type of PTSD, and for kids, that there is a developmental trauma disorder that really include things like dissociation and sometimes difficulties with self-harm, and major challenges in terms of just managing intense emotions. All understandable as reactions to the experiences that they've had, and as really adaptive reactions to survive the trauma that they've experienced. And that's how I've come around to being a trauma-focused therapist, but not because I think trauma is everything, but because I think so much of what we see as therapists and counselors, whether it's symptoms of depression or anxiety, or addictive disorders, that so much of that is related in part, not necessarily always, but in part to just having coped with and survived trauma and having had to basically deploy adaptive resources, abilities that, again, I just usually don't even have myself.
Julian Ford, PhD: (10:16)
Yeah.
Keith Sutton, Psy.D: (10:16)
Yeah. So,
Julian Ford, PhD: (10:18)
That's, that's my long story.
Keith Sutton, Psy.D: (10:20)
No, that's great. I mean, I think that's such a big piece because, you know, oftentimes, so many of, in the clinical samples of folks that are coming to get help might be coming for, you know, panic attacks or something, you know, substance abuse, but then not realizing that there's this whole other aspect, the complex PTSD that might be going on or so on, and that all has an interplay. So it's kind of like the tip of the iceberg. And, I think a lot of therapists also aren't sometimes as,-- and I wasn't; it wasn't untill, you know, several years ago that I really, like, understood complex PTSD and the difference between that and, and other types of trauma. And I would love to hear the way that you maybe discuss or, kind of talk about CPTSD versus, -- yeah, just other, trauma.
Julian Ford, PhD: (11:08)
Yeah, sure. Well, the major difference, I think, is that complex PTSD, and as I said, with kids, we've thought of this as more of a developmental trauma disorder. But, either label, it's the same essential phenomenon, and that is attempting to basically process on an ongoing basis a sense of threat. So the common denominator here is whether the threat comes from abuse, neglect, violence, exploitation or betrayal. Traumas -- as Jennifer Fryd has described so eloquently, whatever that source may be, the survivor is so often left with the sense of never really being able to feel safe. And I know that may sound very simplistic, but the ways in which that takes shape in each individual are completely unique for every person. The way in which that affects a person--that's why --I'll just segue for a second.
Julian Ford, PhD: (12:19)
That's why in developing this approach to therapy, which is intended to be a, a compliment for other approaches, not a competitor-- the approach to therapy that I've been working with is really focused on helping people understand that what happens when we experience the kinds of incredible life threats or life-altering experiences that are traumatic is that there are shifts in the brain. And we don't know all of this, and I'm not a neurobiologist, I'm an informed consumer of the wonderful work that neuroimaging and other kinds of neurobiological researchers are doing. But what I've come to learn--and I've seen this validated by the clients who I work with, is that it's essentially that an area in the brain that we think of as like an alarm, and it's not it. We talk about it in terms of the amygdala, which is in the kind of the emotional part of the central brain.
Julian Ford, PhD: (13:22)
It's more than that, but that's, that's enough. And to have the-- what I've learned is it's like having an alarm going off in your body and not just your brain, but your whole body all the time. And of course, people who are experiencing complex PTSD, and this is true for PTSD as well, but it's just, it's even more so with complex PTSD because the triggers for that alarm, become much more complex as the kinds of trauma that people have experienced has been more complex. So for an individual experiencing PTSD, they may be reminded of and, have a kind of an alarm reaction. Sometimes it's called a startle reaction. Yeah. It could also be a shutdown and a freeze reaction as well. And that, that may be triggered by a specific place or a time or a kind of a situation that is reminiscent of something that's happened.
Julian Ford, PhD: (14:22)
For someone with complex PTSD, it's often much more, much broader than that. It's just being around people, even especially people who are kind or nice to you or who you think you can trust because in many cases, those are the people who then betrayed that individual's trust. And so the complexity of the reaction is not irrational. It's entirely rational. Yeah. But it is pervasive. So just imagine living with an alarm going off in your body and your brain all the time, and you're just trying to kind of cope with that and figure out what should you be paying attention to? Where's the danger going to come from? Why are you so tense and on guard or so shut down and exhausted when everybody else seems to be fine? And you can't really see any particular problems, and the trauma is not happening now.
Julian Ford, PhD: (15:13)
Although for some, it is still, so that, I think is what the dilemma of complex PTSD.
Keith Sutton, Psy.D: (15:21)
Yeah.
Julian Ford, PhD: (15:22)
So, and then it spills over into beliefs about the world being safe, about people being safe, and not about oneself being a person who deserves to be cared for and protected versus somebody who just deserves to be traumatized or is, somehow causing trauma to happen.
Keith Sutton, Psy.D: (15:43)
Yeah.
Julian Ford, PhD: (15:43)
It spills over into emotions, and so that's where, you know, panic and anxiety and depression and difficulties with anger, It spills over into just looking for some kind of positives in life and it can lead to then addictive searching, not for something positive, but moreso for relief from that alarm. So I probably told you more than you wanted to know, but -
Keith Sutton, Psy.D: (16:09)
No, it's great.
Julian Ford, PhD: (16:10)
That's how complex, complex PTSD is.
Julian Ford, PhD: (16:12)
But it's also when you tell people about the fact that they've got an alarm in their brain and that it has been triggered to be on a high level of activity and, and readily, and just hair triggered to be set off again, I've had more people tell me, "Oh, well, that, that makes sense. Why didn't anybody ever tell me about that before? Now, how do I turn down and reset that alarm in my brain?" And that's what I think we're, we're really helping people to do when we do therapy in a way that helps an individual, not just to say, "Oh, I'm safe now, and that was then and this is now," all of which is good, but much more to, to be able to recognize those reactions as coming from past experiences or experiences that may be current, but that are not happening right at this moment, and that they can then-- rather than trying to basically find what to do about this alarm, they can literally use the thinking area of the brain, the prefrontal cortex to send a signal back to that alarm. And that's not psychosurgery.
Keith Sutton, Psy.D: (17:25)
Sure. Yeah.
Julian Ford, PhD: (17:27)
But that's what we do in therapy is we help people to be able to formulate ways of thinking and relating and feeling safe in relationships that then enables them to literally inform the alarm in their brain that they are actually safe now. And that's the fundamental shift. And that can take sometimes weeks, sometimes months, sometimes years.
Keith Sutton, Psy.D: (17:51)
Definitely. Yeah, even though I feel unsafe, I am safe in this moment.
Julian Ford, PhD: (17:57)
Exactly. And I know why I feel unsafe. It's not because I'm crazy. It's not because there's something wrong with me. It's because I have a perfectly healthy part of my body that has been attuned to protecting me. And, nobody ever told me that, and nobody ever told me there's no handbook for how do you turn down the alarm in the brain. There are stress management exercises, there are relaxation exercises, there are meditative approaches, all of which can be helpful. But what I found is that if the individual doesn't have that kind of internal sense, a mentalized picture of what's happening in their body and their brain, then all of those other wonderful approaches to calming the body and gaining a sense of internal confidence and safety and calm, that those can literally just kind of go right past this whole dilemma, leaving an alarm that is still set at a high level.
Keith Sutton, Psy.D: (18:57)
Yeah. So just that aspect of knowing and understanding this, knowing like, okay, this is what's going on, rather than this is unsafe or I'm crazy or whatever it might be is engaging that frontal lobe, that prefrontal cortex.
Julian Ford, PhD: (19:13)
Exactly, that's right. And probably many other areas of the brain too. Of course, definitely. But especially that particular area. And engaging it in a way, engaging us in thought where we're also probably thinking about, you know, what does this mean for me? And that's why it's so important. We don't always explore trauma memories in therapy for people with PTSD or complex PTSD. We often do, we don't always. But when we do help them to explore trauma memories, if they choose to do that--and I think that's really important that that's the individual's choice--then what we find and what we help the individual find is not just how awful it was. And sometimes that is part of it to- to really be able to fully experience the intensity of the shock or the, the fear or the hurt.
Julian Ford, PhD: (20:05)
But maybe even more importantly, we help them to begin to recognize, "This is how I got through that, this is what I was able to do, these are the core values that helped keep me alive." These are the ways in which I thought myself to a new place in my life in spite of the abuse or the violence.And so what we actually help people find is that in the memories that they have that are really awful memories in many cases, what's most important is not what happened to them, but what they were able to do in order to carry on with their life.
Julian Ford, PhD: (20:43)
You can't avoid facing what happened. But you don't have to stay stuck with that. In fact, that's not a good endpoint for trauma memory processing. . The crucial endpoint is: I went through this. I know as much as I need to know about that and not necessarily every detail. And what I also know that's most important is this is how I brought with me some of the core values, strengths, abilities, some of who I am and that's what enabled me to survive, not by just simply gritting my teeth and getting through it. I survived and I brought forward these abilities and these strengths. And that's what-- it's wonderful for me to see people begin to, to recognize that, oh my gosh, t's not that I'm so confused and I can't think straight at all or that I'm so dissociated that I just lost my ability to focus and make good decisions.
Julian Ford, PhD: (21:42)
It's that my mind and my brain have been very busy. And I haven't realized that I've needed to sort this out in a way where I could recognize not only what happened to me, but also how I was able to bring myself through that and how I'm able to continue on in my life using those same abilities, but not just for survival. To actually accomplish what's important to me in my life.
Keith Sutton, Psy.D: (22:07)
Definitely.
Julian Ford, PhD: (22:08)
And it's making that kind of a connection. Then the trauma memory is not a memory primarily of trauma, it's a memory of recovery.
Julian Ford, PhD: (22:18)
And that's why Judith Hurman writes about trauma and recovery.
Keith Sutton, Psy.D: (22:21)
So yeah, you're saying that like, the person's kind of realizing their coping, and how they were coping or how their mind was coping and understanding how that was helping them through the survival situation. And that some of those aspects can also continue to be helpful in the future, although in the state of survival may not be as helpful or as--you know, kind of like efficient. Or I'm almost thinking like in, internal family systems, you've got these managers and firefighters and so on. And then once you get to know them and they realize that they're not in that survival situation anymore, they begin to kind of be able to still be utilized. They don't have to go away or not do these things anymore, but in a different way when it's not out of survival.
Julian Ford, PhD: (23:14)
Exactly. That's right. It's no longer about fight or flight. It's about moving forward in your life and being able to accomplish what's important to you. And that's, what we also, we help in this target therapy approach, which is not the store.
Keith Sutton, Psy.D: (23:32)
Sure. Well, it sounds like you're honoring, right. We're honoring the survival mechanisms that we're--
Julian Ford, PhD: (23:39)
We're honoring the core inner self that has enabled that person to survive. And that self has capacities and abilities that then had to be deployed for survival when that was the agenda.
Keith Sutton, Psy.D: (23:54)
Yeah. Yeah.
Julian Ford, PhD: (23:56)
They also can be deployed not to fight or flight, but to accomplish goals, to achieve the kind of life that's important, to live our values in many ways. And it's shifting that focus from always having to, to just basically be in survival mode, even though it may look like I'm a perfectly successful and happy and resilient person, and am a resilient person. But shifting from that focus of I'm just pretending that life is okay while I'm always watching for whatever the next terrible thing is, that's going to happen to, okay, I need to be aware that things can happen. There's no guarantees, but now I can see that I can trust myself and I can trust my ability to make decisions and to choose relationships where it's not just about survival. It's also about what I truly believe is most important in my life.
Julian Ford, PhD: (24:52)
And that's what we help people focus on in this therapy. We don't avoid the trauma aspects and the pain and the difficulties, but we also use that as the beginning, and then we bridge to who are you as a person and how did you find a way through this? And what does that tell you about yourself and your life moving forward? So then it becomes much more of a focus of how can I recognize and build on and utilize who I am as a person rather than believing that I was completely broken and damaged, even though that may be the way the person, the individual felt at the time because trauma is so difficult and so damaging.
Keith Sutton, Psy.D: (25:42)
Definitely. So you're bringing up so many great pieces. I want to check in on the nervous system piece, because one of the ways that I've conceptualized CPTSD is being in prolonged periods of fight or flight, and the nervous system getting kind of wired in this way — particularly if it's in childhood. It could be as extreme as physical or sexual abuse, it could be an unpredictable, erratic parent, or even a neglectful parent — but basically, did the kid feel like they could just sit back and go for the ride and let their parents take care of things, or did they feel like they had to take care of themselves? That nervous system piece — that reactive nervous system aspect — is so difficult, and there's been a number of studies on the brain and how that's affected.
Keith Sutton, Psy.D: (26:34)
I'm curious about your thoughts, or the different approaches you're using in your work. I know there's lots of different approaches — sensory, somatic approaches, EMDR, brainspotting, neurofeedback — all these things kind of helping with that bottom-up processing, that nervous system regulation. In the approach you're using, there's one aspect that sounds kind of like what Dan Siegel talks about — connecting the upstairs and downstairs brain, right? That amygdala, with the prefrontal cortex realizing, "Okay, I know what's going on here, this is a trigger." What other kinds of things do you use with clients in your approach to help with the dysregulation?
Julian Ford, PhD: (27:25)
Well, I work with people based upon their specific focus in life. Some people are really highly focused on emotions, and if that's the case, then we'll do a very much emotion-focused approach — helping them identify and recognize differences between their emotions, so that they're not just feeling generically bad, or blah, or nothing at all. To begin to articulate, if that's important to them, what they're feeling on an emotional level — that's the language I use, and that's the way I'd approach it. If they're more intellectualized — in a positive sense, living a lot in the world of their thoughts — then we'll focus on their core beliefs and thoughts that are triggered by specific situations that may be reminders of trauma, or of what was lost or missed because of trauma.
Julian Ford, PhD: (28:36)
If they're really much more focused on their body, then I will definitely help them just pay more attention to their body — how they feel at different times, how they're feeling in the moment as we're talking, if we're talking in therapy — and subtle shifts, watching carefully for changes in posture and body orientation, and other nonverbal signs that individuals are often not aware of themselves. So I guess, Keith, basically what I'm saying is I try to focus on whatever the metaphors and the language and the modalities are that each client is most comfortable with and finds the most meaning in. Across all of those modalities, whether it's bodily or behavioral — and there are times where I'll talk with people about choices they have about things they can actually do. I don't tell people what to do, but to —.
Julian Ford, PhD: (28:36)
Activate them, to get some behavioral activation going. So whatever the modality is, what I've found really important is to always start with what's troubling the individual, and then help them begin to shift — carrying that as a foundation — to what is it that they truly value and that's important to them, not so much what they just want.
Keith Sutton, Psy.D: (30:07)
Yeah.
Julian Ford, PhD: (30:07)
How do they know when they're feeling that way emotionally — when their body is feeling that sense of contentment, calm, and security — and begin to actually help the individual pay attention not only to the stress response, but also to the often more opaque and difficult-to-see response where they are truly at rest.
Keith Sutton, Psy.D: (30:33)
Yeah.
Julian Ford, PhD: (30:35)
And that may be, only very brief periods where that's the case. Especially when I'm working with kids, with teenagers, especially. I mean, they hardly ever settle down .
Keith Sutton, Psy.D: (30:47)
Sure, sure.
Julian Ford, PhD: (30:50)
I've been, I've been fired by more teenagers as a therapist than anybody else, than by anybody else that is. But what I've always found is important is to help them to just catch moments. So for example, I, I'll just give you one example without any specific identifying information for privacy's sake. But I'm thinking about, in one instance, there was a young man who, he, he was required to come in for therapy because he had anger management issues, and one of the things that he'd said to his anger management, group leader after--I think it was the third or the fourth time that he'd been through anger management --was the a - the group leader said, "Why don't you use your anger management skills? You could teach anger management better than I can. You know all of this stuff." And, and the young man said, and this is actually a true story, he said, "Oh, I can use my anger management skills anytime except when I'm angry."
Keith Sutton, Psy.D: (31:54)
Yeah.
Julian Ford, PhD: (31:54)
So what I was thinking, as I was talking with this young man, was: okay, how am I going to be able to show him what he's capable of? I'm not going to try to teach him something that he then has to layer onto what he's already doing, because he's already got his way of approaching things — he just doesn't know what to do when that alarm gets triggered. A lot of the time when we talked, he was on his cell phone, paying very little attention to me, and I just tried to be patient and not go too deep into my fear that I was making no difference and doing nothing about it — which were clearly strong fears, though. But at one point he brought in his phone and said, "I want you to watch this." He had filmed a couple of kids at his school fighting.
Julian Ford, PhD: (32:45)
And I said, "You know, I'm not that comfortable watching a film of your classmates fighting." He said, "No, no, you've got to see this. You've got to see this." So I was thinking, "Well, okay, he's telling me something here. What is he telling me?" So I said, "All right, I'll watch this, but I'm going to watch it only to see your camera technique. I want to see how you made choices about what to film and whatnot." And it turned out that he would maneuver all around these kids who were fighting to get different angles, and then he did a post-fight interview with a couple of them. None of which was easy to see or think about. But what I learned from that, and was able to tell him, was that he had the ability to see things in a way that most people don't.
Julian Ford, PhD: (34:30)
And I could see that was a skill he had been using through a series of placements, foster homes, and residential treatment programs. He had a way of seeing when he needed to get out, and he would then do something to get himself sent to another setting. I suggested to him that maybe this was actually a really important ability he had, that he was using it to kind of fend off problems — and I understood that he needed to do that — but this might be an ability he had that not everybody has, that could actually be really important. He sort of said, "I don't know, I don't know," but I could see he took a moment, and it was a seed that was planted.So that's what I think about in doing therapy. Sometimes people are just really able to talk through things — they're just primed to discover more about themselves, and that's wonderful. Other times, it's not that easy. What I've found is that hopefully what I can do is show them something about themselves that they can take with them, and potentially be able to use in situations that come up, in a way that is not just to survive. And that's probably not the explanation you were expecting, but that's okay.
Keith Sutton, Psy.D: (34:30)
That's very helpful. I like what you're saying — that you're kind of tailoring it to the client specifically, and looking at where their inroad is, whether it's the emotions or the core beliefs. And I wanted to go to this piece you mentioned about who they are as a person. I know one of the aspects of CPTSD is one's sense of self. The way I've thought about it is that, oftentimes, growing up in an invalidating environment — say the parent smacks a kid, the kid starts crying, and the parent says, "Why are you crying?" — the child begins to question their own sense of reality, and starts basing what's happening on others' reactions, which can lead to codependency sometimes.
Keith Sutton, Psy.D: (36:00)
If they're happy with me, I'm good. If they're unhappy with me, I'm bad. That sense of self really rises and falls with what's happening in the circumstance or the moment, rather than having a more consistent sense of self. So I'm hearing that there's a big aspect of this — getting to know one's self and one's values. It reminds me of Acceptance and Commitment Therapy — connecting to those values, and not bouncing around depending on what's happening in the situation, but really moving toward those values despite discomfort or avoidance.
Julian Ford, PhD: (36:39)
Exactly. You've described it perfectly — as basic as that may seem, I think it's really complex and challenging for most of us to step back and actually consider: okay, who am I as a person? Not so much what I've been told about who I am, or how people treat me — even though those are important influences — but who do I know myself to be, through my own eyes? And that, of course, isn't just a matter of philosophical sitting back and pondering. It's very much something we're all trying to figure out every moment of every day: who am I in this situation? What do I believe in? What are the values that can guide me through this challenging situation, whether it's an ordinary day-to-day situation or a traumatic one?
Julian Ford, PhD: (37:42)
And the idea is that people who've experienced trauma so often — whether it's literally a DSM-5 traumatic stressor, or a validating environment, as you were describing, which is also equally traumatic, just in a different way — whatever that individual has experienced has shown them a view of themselves as shattered, fragmented, messed up, weak --
Julian Ford, PhD: (38:16)
Insufficient, unworthy, and, complex PTSD, that's really a core aspect that the sense of that I'm just worthless or I'm a failure.
Keith Sutton, Psy.D: (38:26)
Toxic change.
Julian Ford, PhD: (38:27)
Or that I'm so damaged that I can never be fixed. So again, rather than saying, "Well, you're a whole person, and we're going to make sure you think of yourself as somebody who is entirely worthy because you are human" — of course that's true — I think people who've experienced trauma and invalidation, or both, need to be able to discover for themselves who they are. And that's where I think we as therapists are capable of being really wonderful mirrors, because we can see, in experiences they might think of as entire failures, how they actually thought it through, and within the limits of what was possible in that situation, made choices that were actually very wise. And they also may have had to make choices, or deal with dilemmas, where they couldn't be entirely consistent with their core values.
Julian Ford, PhD: (39:27)
And that the courage to face that, and to nevertheless deal with those situations, is a mark of who they are as a person — not the fact that they couldn't perfectly live their values. So I find that many times the clients I've worked with over many years — sometimes for many years — will often say, "Oh, there you go again, trying to make me feel good about myself. Trying to tell me something that's good about me. I get kind of tired of you always seeing something good in what I was able to do." And of course, I don't just see something good, but I always think it's important to find within the experience, whether it's a current stressor or a past trauma experience, ways in which that person was able to do things they didn't realize reflect who they are as a person --
Julian Ford, PhD: (40:28)
In spite of the fact that they may not have been able to control much of the situation, and may have been deeply hurt by what happened as well. So that's why, my way of thinking about this, it's not as simple as just giving people positive reinforcement or praise. It's very much helping them discover, in their experiences, who they are in a way they hadn't realized. So if they have multiple self-states, as you were describing — as in dissociative identity disorder, or the Internal Family Systems approach — those self-states represent aspects of the individual, and that's how I think it's really important to approach people. I don't specifically help them identify different self-states, but if they do that spontaneously, and see themselves or experience themselves in very different ways, what I see as my fundamental responsibility is to help them see the person who's in there across all of those self-states.
Keith Sutton, Psy.D: (41:39)
Yeah.
Julian Ford, PhD: (41:40)
And of course, each of us is going to be very different depending on the situation. Sometimes we're going to be angry and fight back. Sometimes we're going to run the heck away. Sometimes we're going to stand our ground. Sometimes we're going to protect. Sometimes we'll take care of others, even at the cost of ourselves. And again, it's not to judge any one of those reactions, but more to see what's the core value in all of that. Is it a sense of needing to be loyal to those who trust you? Needing to be honest, even at times when honesty may have a great price? Is it a sense of needing to treat others the way you would want to be treated — the golden rule, as simple as that may seem?
Keith Sutton, Psy.D: (42:24)
Yeah. Yeah.
Julian Ford, PhD: (42:25)
So finding that core self that runs through and is really focused, largely, on core values and core goals in life — that I see as the ultimate challenge for all of us, whether we're doing EMDR, cognitive processing therapy, prolonged exposure, experiential therapy, or psychodynamic therapy. Each of those has different ways of helping people begin to see themselves more fully. And I just think it's really crucial that, regardless of the therapy modality, we're always, as therapists, thinking about: what am I showing this person about who they are?
Keith Sutton, Psy.D: (43:08)
Sure. Sure.
Julian Ford, PhD: (43:09)
Not proving to them that they're better than they think they are, but showing them who they are and in a way that reflects their, their core self --which is intact even if they feel very shattered.
Keith Sutton, Psy.D: (43:22)
So you've kind of got that radar detector out for those values that are inherent within what you're hearing or seeing — those trauma stories — really seeing those within, to be able to help reflect those to the clients, for them to see those pieces that are there.
Julian Ford, PhD: (43:44)
Yes.
Keith Sutton, Psy.D: (43:45)
Yeah, that might be covered up by all the other stuff, the trauma, the reactivity, the, you know, all those kind--
Julian Ford, PhD: (43:52)
Well, and gosh, people have complex lives, especially if they've experienced trauma. So there are so many complexities, and it's really like a smoke screen. It's hard for anybody to see through that. But I think we as therapists have that opportunity to do that, and to help our clients begin to do that too.
Keith Sutton, Psy.D: (44:14)
Sure. Now, I'd like to touch on, if we could go back to the piece around missing the diagnosis of trauma with children, and potentially having an ODD or ADHD diagnosis instead. What do you make of that, or what are your thoughts on why that might happen? I think that's oftentimes the fear of a therapist who doesn't understand some of those diagnoses as well — that the label's just going to get slapped onto a kid, and you're going to miss what's really underneath it. And that happens. And I think sometimes people might go to the other extreme, where they become more reluctant to give some of those diagnoses, for fear of not really addressing what the core pieces are, or so on.
Keith Sutton, Psy.D: (45:03)
Yeah, what are your thoughts or what through the research were you all finding around why those misdiagnoses were happening? I know you alluded to it earlier a little bit too, but yeah.
Julian Ford, PhD: (45:13)
Well, I think it's an "and," not an "or." So in so many cases, kids will be legitimately diagnosed with ADHD or ODD because they are experiencing difficulties with attention, hyperactivity, or oppositionality, and just kind of aggression, or at least resistant behavior. So those are real, and I think that's why it's really important in treatment to have access to modalities — whether they're pharmacological or more behavioral, parent, and behavior management approaches — to help kids who have attentional difficulties with executive function, working memory, and processing. So all of that is very important. And then, in addition, I think what we can add to that is: if we know from a child or from their caregivers that this particular child has experienced traumatic threats or traumatic experiences of any kind, and if some of their difficulties with attention, arousal, behavior, and attitude are fairly reliably triggered in certain situations, by certain kinds of interactions, that are then either likely or potentially related to experiences that have been very stressful or even traumatic for that kid --
Julian Ford, PhD: (46:52)
That if we can take that into account, you don't necessarily have to do trauma-focused cognitive behavioral therapy. You can — and even my wonderful colleagues who do TF-CBT, and I do it at times as well, although I'm not as well-trained as I should be — it's not always the case that a trauma narrative is done in trauma-focused CBT. There are many other ways in which the child and their caregivers are helped to understand the reactions as ways of reacting that are exactly what I'm talking about, because of that kind of internal alarm, and ways they can then turn that alarm down, so that it's not just ready to go off and interfering with concentration or attention, or triggering hyperarousal or reactive behavior. So I think the important thing we've figured out is: if you're working with a kid who meets criteria for one of those disruptive behavior disorders --
Julian Ford, PhD: (47:57)
That if you also know enough about their life story, and are being careful in doing a kind of behavior-analytic approach — looking at what the discriminative stimuli are that are associated with the problem behavior, and the consequences that may then unfortunately reinforce that behavior — if you look at that very carefully, you may find that for many of these kids, some of those kinds of triggering and reinforcing situations are related to aspects of the trauma they've experienced. It wouldn't necessarily be exactly the same thing — it could be just a reminder of something similar, even as subtle as somebody who has a certain facial expression, that then triggers a reaction. Then it becomes possible to help that kid and the caregivers recognize, "Okay, so these are reactions that make sense, given that you've been through something that was very stressful."
Julian Ford, PhD: (49:05)
"And so let's plan for how you can handle those situations, or we can help you in those situations, or prevent those kinds of situations." And that, in that sense, is where it becomes trauma-informed therapy, whether or not it's trauma-focused specifically. And that's what I think can be a really big advantage, because I meet with our child psychiatry fellows who are working with kids who've been through all kinds of really tough experiences, and have pretty severe psychiatric problems. And every time we talk about a case, we talk about that child's or teenager's life — what they've been through, the good and the bad — and as we begin to put together a picture of what that child's life has been like and what they've learned, it informs the fellow about how they can approach the treatment in a way that then reduces some of the trauma reminders--
Julian Ford, PhD: (50:04)
Or helps the child, teenager, or their parent or caregiver respond when there is that kind of reminder, and recognize that once you know how to respond to it, it becomes less likely to be triggering. That's the benefit I can see. So again, if there's no trauma history, if there's no connection to past experiences, then don't add that on.
Keith Sutton, Psy.D: (50:32)
Well, and I think it's so difficult because there's such an overlap — kids with ADHD have higher levels of PTSD, because there's an interplay around symptoms, heritability, and parent symptoms, as well as with oppositional defiant disorder. There are many, many roads that lead to Rome on that. I don't really like the oppositional defiant disorder diagnosis, because it's not something that's within the child, but I do like it in that it's one of the only systemic diagnoses in the DSM, looking at the pattern of interactions that might be happening between parent and child, or parent, child, and teacher, or whatever it might be. But yeah, there's often that overlap, and I think a lot of therapists get caught up on: is it ADHD, is it trauma? And really, oftentimes, it's for the psychiatrist to determine what appropriate medication might be, but as a therapist, you're still going to work with the kid and the parent, helping those things be less volatile and more warm and connected, as well as helping with dysregulation — and maybe that is related to the trauma, so you do more trauma work, or maybe that's just working on the dysregulation anyway.
Keith Sutton, Psy.D: (51:47)
So those are, I think big pieces.
Julian Ford, PhD: (51:50)
Exactly. And I'm glad you mentioned the systemic approach, because my original training was as a family therapist — so I'm remiss in not having factored that in, helping the child or adult, and other members of their family, figure out how their reactions are interwoven and affecting one another, and then helping them begin to discover some of the shared core values that they have. That's what I learned in my family therapy training 50 years ago. (laughs) If we can find some shared core values, then we have the beginnings of a way to bridge the gap that can grow up between people, or the conflict that can tear them apart.
Keith Sutton, Psy.D: (52:44)
Yeah, definitely. Well, that's great. So can you tell a little bit about, like, how folks can learn more about the approach that you have developed and the target model? And is there, I think you've written some books. Is there trainings? There's research articles.
Julian Ford, PhD: (53:03)
Well, there are some of all of that. But to keep it simple, I will suggest there are two websites. I'm very fortunate to have been able to start, and now continue, two centers within what's called the National Child Traumatic Stress Network — that's a federally funded set of centers all across the country. The two I've been involved with have websites, and the best place to get information on both the TARGET model, on developmental trauma, and complex PTSD would be to go to — so first is the Center for Trauma Recovery and Juvenile Justic
Julian Ford, PhD: (53:51)
And the second is the Center for the Treatment of Developmental Trauma Disorders. And I will be glad to--I'll send you those websites.
Keith Sutton, Psy.D: (54:01)
Perfect. And I'll link them in the bio on the website too, because that would be a great resource for folks — because this is such an important area, and the research I was originally drawn to is what happens when it gets missed, or gets mixed up, and maybe the therapist is sometimes missing pieces of those puzzles that are really important. And I think for many of us — I know I didn't really get the depth of training to really understand CPTSD until I was looking at my own caseload, and at the folks I'd been working with the longest who hadn't graduated, and I noticed the common thread that ran through was CPTSD. So I think it's such an important area for clinicians to get trained in, because if you don't really understand it or wrap your mind around it, you can miss that really important aspect.
Julian Ford, PhD: (54:55)
If you don't know to look for it, you'll never see it.
Keith Sutton, Psy.D: (54:58)
Exactly. Right.
Julian Ford, PhD: (54:59)
And if you do look for it, you won't always see it.
Keith Sutton, Psy.D: (55:03)
Yeah, yeah. Well, thank you so much. I really appreciate you taking the time, I really appreciate it. Thank you.
Julian Ford, PhD: (55:10)
Thank you, Keith. It's been a real pleasure talking with you.
Keith Sutton, Psy.D: (55:13)
Yeah. Bye-bye. Thank you for joining us today. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults with our licensed, experienced therapists — in person in the Bay Area or throughout California online — and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships, and low-fee treatment through our nonprofit, Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need, and training in evidence-based treatments, you can donate by going to BACC's website at sf-bacc.org. BACC is a 501(c)(3) nonprofit, so all donations are tax-deductible. Also, we really appreciate your feedback.
Keith Sutton, Psy.D: (56:20)
If you have something you're interested in — something that's on the cutting edge of the field of psychotherapy, that you think therapists out there should know about — send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training and evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on-demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our lifespan centers, Center for Children, and Center for Adolescents, where all the therapists are working systemically, our Center for Couples, where all the therapists are using emotionally focused couples therapy, and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our Center for ADHD and Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D: (01:32)
At the Institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com, and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 nonprofit, so all donations are tax deductible. Today, I'll be speaking with Julian Ford, a clinical psychologist who is a professor of psychiatry at the University of Connecticut School of Medicine, where he is the director of the Center for Trauma Recovery and Juvenile Justice, and the Center for the Treatment of Developmental Trauma Disorders.
Keith Sutton, Psy.D: (02:33)
He has served as president of the International Society for Traumatic Stress Studies, and is a fellow of the American Psychological Association and the International Society for Traumatic Stress Studies, is editor of the Journal of Trauma and Dissociation, and associate editor of the Journal of Racial and Ethnic Health Disparities. Julian has published more than 350 articles and book chapters. He is author of Crisis in the Psychotherapy Session: Transforming Critical Moments into Turning Points, co-editor of Treating Complex Traumatic Stress Disorders in Adults, Second Edition, and Treating Complex Traumatic Stress Disorders in Children and Adolescents, and co-author of Treatment of Complex Trauma: A Sequenced Relationship-Based Approach. His research focuses on developmental trauma disorder and the Trauma Affect Regulation: Guide for Education and Therapy Therapeutic Intervention called Target. Let's listen to the interview.
Hi, Julian. Welcome.
Julian Ford, PhD: (03:28)
Thank you, Keith. Great to talk with you.
Keith Sutton, Psy.D: (03:31)
Yeah, thanks so much for taking the time today. So, I ended up learning about your work. I was doing some research on the differential diagnosis with ADHD and complex PTSD, which then led me to some of the work that you did, an article in 2000 on developmental trauma disorder and coming up as ADHD or oppositional and some of the overlaps in the symptomatology, and then reached out to you and got to learn more about your work and your target model, which sounds really great, a cognitive behavioral therapy model that adds on an aspect of affect regulation that sometimes isn't there, in other models based on neurobiology, which is wonderful. So I want to hear about all these things, but first, I always like to find out, you know, people's journey.
Keith Sutton, Psy.D: (04:20)
How did you get to doing what you're doing? What kind of led to the evolution of your thinking?
Julian Ford, PhD: (04:25)
Well, I've gone through many phases in my career, starting when I was still an undergraduate in college and I worked for a year and a half as a line staff person at a state psychiatric facility. I think that's where I learned so much from the men and women who were the patients there, as well as my colleague. But it took another 20 years or so before I actually realized the impact that trauma has had on so many of the clients that I've seen and that I've had the privilege of seeing since then. So it really wasn't until I started working as a psychologist in the Department of Veterans Affairs in Oregon, back in 1990, so more than 30 years ago, on a PTSD treatment unit.
Julian Ford, PhD: (05:20)
And so I had, for about 10 years, I was able to work with military veterans, men and women who experienced PTSD. And then in that time, I also was able to work at a, a program called the National Center for PTSD, which is actually part of the Department of Veterans Affairs, but it extends well beyond veterans, and at Dartmouth. And there was a wonderful child psychiatry group there who were doing some really unique research on trauma history with kids who were diagnosed with, attention deficit hyperactivity disorder, ADHD, and oppositional defiant disorder, ODD. And that's where that 2000 paper came out. It basically was from a case series of kids who had those diagnoses, but when we inquired more carefully about their trauma histories, many who were diagnosed with oppositional defiant disorder in particular, somewhat also with ADHD, many of them had very significant trauma history.
Julian Ford, PhD: (06:22)
Many of them had PTSD symptoms that had just never really been identified. And then that led me to go on as I came to Connecticut back almost 10 years later, and have been here since then, and working with adults now, and then again, back with teenagers more recently. But the, the common thread I've seen Keith, is that so many kids and adults who are experiencing some of the most difficult symptoms of emotional and behavioral disorders - not only have trauma histories, I think we pretty much know that, but they're also, they're experiencing many of the symptoms of traumatic stress. And often are not identified as having PTSD bebecause it may not be absolutely clear that they have specific memories of traumatic events. Many cases, they may not remember details of or even remember events at all.
Julian Ford, PhD: (07:25)
And these are not repressed memories, they're just memories that are not accessible, just as many of our memories are not accessible as we go through life. And so it just became clear to me that--and this actually goes back to my work with the VA too, because in working with the men with chronic PTSD, it was very clear to me that many of them had difficulties that went well beyond PTSD, and that's right when a group led by Bessel van der Kolk and Susan Roth and David Pelkovitz, and Judith Herman were talking about complex PTSD for the first time. And so I actually did, I made a priority for a program that I was directing then with, which was an inpatient residential program for chronic PTSD. We assessed complex PTSD and we found that a substantial proportion of the men who were in this program not only had PTSD, but they had really significant difficulties with emotion regulation, with their bodies just being completely kind of detached from their awareness in many respects, dissociation of other kinds as well.
Julian Ford, PhD: (08:46)
And again, these are people who are incredibly resilient. . They, , I could never cope as well as they do. I wouldn't be functioning if I'd been through even a fraction of what they've been through. But they also had really significant difficulties that went well beyond PTSD. So I then joined with this group that has been working on the idea that there is a complex type of PTSD, and for kids, that there is a developmental trauma disorder that really include things like dissociation and sometimes difficulties with self-harm, and major challenges in terms of just managing intense emotions. All understandable as reactions to the experiences that they've had, and as really adaptive reactions to survive the trauma that they've experienced. And that's how I've come around to being a trauma-focused therapist, but not because I think trauma is everything, but because I think so much of what we see as therapists and counselors, whether it's symptoms of depression or anxiety, or addictive disorders, that so much of that is related in part, not necessarily always, but in part to just having coped with and survived trauma and having had to basically deploy adaptive resources, abilities that, again, I just usually don't even have myself.
Julian Ford, PhD: (10:16)
Yeah.
Keith Sutton, Psy.D: (10:16)
Yeah. So,
Julian Ford, PhD: (10:18)
That's, that's my long story.
Keith Sutton, Psy.D: (10:20)
No, that's great. I mean, I think that's such a big piece because, you know, oftentimes, so many of, in the clinical samples of folks that are coming to get help might be coming for, you know, panic attacks or something, you know, substance abuse, but then not realizing that there's this whole other aspect, the complex PTSD that might be going on or so on, and that all has an interplay. So it's kind of like the tip of the iceberg. And, I think a lot of therapists also aren't sometimes as,-- and I wasn't; it wasn't untill, you know, several years ago that I really, like, understood complex PTSD and the difference between that and, and other types of trauma. And I would love to hear the way that you maybe discuss or, kind of talk about CPTSD versus, -- yeah, just other, trauma.
Julian Ford, PhD: (11:08)
Yeah, sure. Well, the major difference, I think, is that complex PTSD, and as I said, with kids, we've thought of this as more of a developmental trauma disorder. But, either label, it's the same essential phenomenon, and that is attempting to basically process on an ongoing basis a sense of threat. So the common denominator here is whether the threat comes from abuse, neglect, violence, exploitation or betrayal. Traumas -- as Jennifer Fryd has described so eloquently, whatever that source may be, the survivor is so often left with the sense of never really being able to feel safe. And I know that may sound very simplistic, but the ways in which that takes shape in each individual are completely unique for every person. The way in which that affects a person--that's why --I'll just segue for a second.
Julian Ford, PhD: (12:19)
That's why in developing this approach to therapy, which is intended to be a, a compliment for other approaches, not a competitor-- the approach to therapy that I've been working with is really focused on helping people understand that what happens when we experience the kinds of incredible life threats or life-altering experiences that are traumatic is that there are shifts in the brain. And we don't know all of this, and I'm not a neurobiologist, I'm an informed consumer of the wonderful work that neuroimaging and other kinds of neurobiological researchers are doing. But what I've come to learn--and I've seen this validated by the clients who I work with, is that it's essentially that an area in the brain that we think of as like an alarm, and it's not it. We talk about it in terms of the amygdala, which is in the kind of the emotional part of the central brain.
Julian Ford, PhD: (13:22)
It's more than that, but that's, that's enough. And to have the-- what I've learned is it's like having an alarm going off in your body and not just your brain, but your whole body all the time. And of course, people who are experiencing complex PTSD, and this is true for PTSD as well, but it's just, it's even more so with complex PTSD because the triggers for that alarm, become much more complex as the kinds of trauma that people have experienced has been more complex. So for an individual experiencing PTSD, they may be reminded of and, have a kind of an alarm reaction. Sometimes it's called a startle reaction. Yeah. It could also be a shutdown and a freeze reaction as well. And that, that may be triggered by a specific place or a time or a kind of a situation that is reminiscent of something that's happened.
Julian Ford, PhD: (14:22)
For someone with complex PTSD, it's often much more, much broader than that. It's just being around people, even especially people who are kind or nice to you or who you think you can trust because in many cases, those are the people who then betrayed that individual's trust. And so the complexity of the reaction is not irrational. It's entirely rational. Yeah. But it is pervasive. So just imagine living with an alarm going off in your body and your brain all the time, and you're just trying to kind of cope with that and figure out what should you be paying attention to? Where's the danger going to come from? Why are you so tense and on guard or so shut down and exhausted when everybody else seems to be fine? And you can't really see any particular problems, and the trauma is not happening now.
Julian Ford, PhD: (15:13)
Although for some, it is still, so that, I think is what the dilemma of complex PTSD.
Keith Sutton, Psy.D: (15:21)
Yeah.
Julian Ford, PhD: (15:22)
So, and then it spills over into beliefs about the world being safe, about people being safe, and not about oneself being a person who deserves to be cared for and protected versus somebody who just deserves to be traumatized or is, somehow causing trauma to happen.
Keith Sutton, Psy.D: (15:43)
Yeah.
Julian Ford, PhD: (15:43)
It spills over into emotions, and so that's where, you know, panic and anxiety and depression and difficulties with anger, It spills over into just looking for some kind of positives in life and it can lead to then addictive searching, not for something positive, but moreso for relief from that alarm. So I probably told you more than you wanted to know, but -
Keith Sutton, Psy.D: (16:09)
No, it's great.
Julian Ford, PhD: (16:10)
That's how complex, complex PTSD is.
Julian Ford, PhD: (16:12)
But it's also when you tell people about the fact that they've got an alarm in their brain and that it has been triggered to be on a high level of activity and, and readily, and just hair triggered to be set off again, I've had more people tell me, "Oh, well, that, that makes sense. Why didn't anybody ever tell me about that before? Now, how do I turn down and reset that alarm in my brain?" And that's what I think we're, we're really helping people to do when we do therapy in a way that helps an individual, not just to say, "Oh, I'm safe now, and that was then and this is now," all of which is good, but much more to, to be able to recognize those reactions as coming from past experiences or experiences that may be current, but that are not happening right at this moment, and that they can then-- rather than trying to basically find what to do about this alarm, they can literally use the thinking area of the brain, the prefrontal cortex to send a signal back to that alarm. And that's not psychosurgery.
Keith Sutton, Psy.D: (17:25)
Sure. Yeah.
Julian Ford, PhD: (17:27)
But that's what we do in therapy is we help people to be able to formulate ways of thinking and relating and feeling safe in relationships that then enables them to literally inform the alarm in their brain that they are actually safe now. And that's the fundamental shift. And that can take sometimes weeks, sometimes months, sometimes years.
Keith Sutton, Psy.D: (17:51)
Definitely. Yeah, even though I feel unsafe, I am safe in this moment.
Julian Ford, PhD: (17:57)
Exactly. And I know why I feel unsafe. It's not because I'm crazy. It's not because there's something wrong with me. It's because I have a perfectly healthy part of my body that has been attuned to protecting me. And, nobody ever told me that, and nobody ever told me there's no handbook for how do you turn down the alarm in the brain. There are stress management exercises, there are relaxation exercises, there are meditative approaches, all of which can be helpful. But what I found is that if the individual doesn't have that kind of internal sense, a mentalized picture of what's happening in their body and their brain, then all of those other wonderful approaches to calming the body and gaining a sense of internal confidence and safety and calm, that those can literally just kind of go right past this whole dilemma, leaving an alarm that is still set at a high level.
Keith Sutton, Psy.D: (18:57)
Yeah. So just that aspect of knowing and understanding this, knowing like, okay, this is what's going on, rather than this is unsafe or I'm crazy or whatever it might be is engaging that frontal lobe, that prefrontal cortex.
Julian Ford, PhD: (19:13)
Exactly, that's right. And probably many other areas of the brain too. Of course, definitely. But especially that particular area. And engaging it in a way, engaging us in thought where we're also probably thinking about, you know, what does this mean for me? And that's why it's so important. We don't always explore trauma memories in therapy for people with PTSD or complex PTSD. We often do, we don't always. But when we do help them to explore trauma memories, if they choose to do that--and I think that's really important that that's the individual's choice--then what we find and what we help the individual find is not just how awful it was. And sometimes that is part of it to- to really be able to fully experience the intensity of the shock or the, the fear or the hurt.
Julian Ford, PhD: (20:05)
But maybe even more importantly, we help them to begin to recognize, "This is how I got through that, this is what I was able to do, these are the core values that helped keep me alive." These are the ways in which I thought myself to a new place in my life in spite of the abuse or the violence.And so what we actually help people find is that in the memories that they have that are really awful memories in many cases, what's most important is not what happened to them, but what they were able to do in order to carry on with their life.
Julian Ford, PhD: (20:43)
You can't avoid facing what happened. But you don't have to stay stuck with that. In fact, that's not a good endpoint for trauma memory processing. . The crucial endpoint is: I went through this. I know as much as I need to know about that and not necessarily every detail. And what I also know that's most important is this is how I brought with me some of the core values, strengths, abilities, some of who I am and that's what enabled me to survive, not by just simply gritting my teeth and getting through it. I survived and I brought forward these abilities and these strengths. And that's what-- it's wonderful for me to see people begin to, to recognize that, oh my gosh, t's not that I'm so confused and I can't think straight at all or that I'm so dissociated that I just lost my ability to focus and make good decisions.
Julian Ford, PhD: (21:42)
It's that my mind and my brain have been very busy. And I haven't realized that I've needed to sort this out in a way where I could recognize not only what happened to me, but also how I was able to bring myself through that and how I'm able to continue on in my life using those same abilities, but not just for survival. To actually accomplish what's important to me in my life.
Keith Sutton, Psy.D: (22:07)
Definitely.
Julian Ford, PhD: (22:08)
And it's making that kind of a connection. Then the trauma memory is not a memory primarily of trauma, it's a memory of recovery.
Julian Ford, PhD: (22:18)
And that's why Judith Hurman writes about trauma and recovery.
Keith Sutton, Psy.D: (22:21)
So yeah, you're saying that like, the person's kind of realizing their coping, and how they were coping or how their mind was coping and understanding how that was helping them through the survival situation. And that some of those aspects can also continue to be helpful in the future, although in the state of survival may not be as helpful or as--you know, kind of like efficient. Or I'm almost thinking like in, internal family systems, you've got these managers and firefighters and so on. And then once you get to know them and they realize that they're not in that survival situation anymore, they begin to kind of be able to still be utilized. They don't have to go away or not do these things anymore, but in a different way when it's not out of survival.
Julian Ford, PhD: (23:14)
Exactly. That's right. It's no longer about fight or flight. It's about moving forward in your life and being able to accomplish what's important to you. And that's, what we also, we help in this target therapy approach, which is not the store.
Keith Sutton, Psy.D: (23:32)
Sure. Well, it sounds like you're honoring, right. We're honoring the survival mechanisms that we're--
Julian Ford, PhD: (23:39)
We're honoring the core inner self that has enabled that person to survive. And that self has capacities and abilities that then had to be deployed for survival when that was the agenda.
Keith Sutton, Psy.D: (23:54)
Yeah. Yeah.
Julian Ford, PhD: (23:56)
They also can be deployed not to fight or flight, but to accomplish goals, to achieve the kind of life that's important, to live our values in many ways. And it's shifting that focus from always having to, to just basically be in survival mode, even though it may look like I'm a perfectly successful and happy and resilient person, and am a resilient person. But shifting from that focus of I'm just pretending that life is okay while I'm always watching for whatever the next terrible thing is, that's going to happen to, okay, I need to be aware that things can happen. There's no guarantees, but now I can see that I can trust myself and I can trust my ability to make decisions and to choose relationships where it's not just about survival. It's also about what I truly believe is most important in my life.
Julian Ford, PhD: (24:52)
And that's what we help people focus on in this therapy. We don't avoid the trauma aspects and the pain and the difficulties, but we also use that as the beginning, and then we bridge to who are you as a person and how did you find a way through this? And what does that tell you about yourself and your life moving forward? So then it becomes much more of a focus of how can I recognize and build on and utilize who I am as a person rather than believing that I was completely broken and damaged, even though that may be the way the person, the individual felt at the time because trauma is so difficult and so damaging.
Keith Sutton, Psy.D: (25:42)
Definitely. So you're bringing up so many great pieces. I want to check in on the nervous system piece, because one of the ways that I've conceptualized CPTSD is being in prolonged periods of fight or flight, and the nervous system getting kind of wired in this way — particularly if it's in childhood. It could be as extreme as physical or sexual abuse, it could be an unpredictable, erratic parent, or even a neglectful parent — but basically, did the kid feel like they could just sit back and go for the ride and let their parents take care of things, or did they feel like they had to take care of themselves? That nervous system piece — that reactive nervous system aspect — is so difficult, and there's been a number of studies on the brain and how that's affected.
Keith Sutton, Psy.D: (26:34)
I'm curious about your thoughts, or the different approaches you're using in your work. I know there's lots of different approaches — sensory, somatic approaches, EMDR, brainspotting, neurofeedback — all these things kind of helping with that bottom-up processing, that nervous system regulation. In the approach you're using, there's one aspect that sounds kind of like what Dan Siegel talks about — connecting the upstairs and downstairs brain, right? That amygdala, with the prefrontal cortex realizing, "Okay, I know what's going on here, this is a trigger." What other kinds of things do you use with clients in your approach to help with the dysregulation?
Julian Ford, PhD: (27:25)
Well, I work with people based upon their specific focus in life. Some people are really highly focused on emotions, and if that's the case, then we'll do a very much emotion-focused approach — helping them identify and recognize differences between their emotions, so that they're not just feeling generically bad, or blah, or nothing at all. To begin to articulate, if that's important to them, what they're feeling on an emotional level — that's the language I use, and that's the way I'd approach it. If they're more intellectualized — in a positive sense, living a lot in the world of their thoughts — then we'll focus on their core beliefs and thoughts that are triggered by specific situations that may be reminders of trauma, or of what was lost or missed because of trauma.
Julian Ford, PhD: (28:36)
If they're really much more focused on their body, then I will definitely help them just pay more attention to their body — how they feel at different times, how they're feeling in the moment as we're talking, if we're talking in therapy — and subtle shifts, watching carefully for changes in posture and body orientation, and other nonverbal signs that individuals are often not aware of themselves. So I guess, Keith, basically what I'm saying is I try to focus on whatever the metaphors and the language and the modalities are that each client is most comfortable with and finds the most meaning in. Across all of those modalities, whether it's bodily or behavioral — and there are times where I'll talk with people about choices they have about things they can actually do. I don't tell people what to do, but to —.
Julian Ford, PhD: (28:36)
Activate them, to get some behavioral activation going. So whatever the modality is, what I've found really important is to always start with what's troubling the individual, and then help them begin to shift — carrying that as a foundation — to what is it that they truly value and that's important to them, not so much what they just want.
Keith Sutton, Psy.D: (30:07)
Yeah.
Julian Ford, PhD: (30:07)
How do they know when they're feeling that way emotionally — when their body is feeling that sense of contentment, calm, and security — and begin to actually help the individual pay attention not only to the stress response, but also to the often more opaque and difficult-to-see response where they are truly at rest.
Keith Sutton, Psy.D: (30:33)
Yeah.
Julian Ford, PhD: (30:35)
And that may be, only very brief periods where that's the case. Especially when I'm working with kids, with teenagers, especially. I mean, they hardly ever settle down .
Keith Sutton, Psy.D: (30:47)
Sure, sure.
Julian Ford, PhD: (30:50)
I've been, I've been fired by more teenagers as a therapist than anybody else, than by anybody else that is. But what I've always found is important is to help them to just catch moments. So for example, I, I'll just give you one example without any specific identifying information for privacy's sake. But I'm thinking about, in one instance, there was a young man who, he, he was required to come in for therapy because he had anger management issues, and one of the things that he'd said to his anger management, group leader after--I think it was the third or the fourth time that he'd been through anger management --was the a - the group leader said, "Why don't you use your anger management skills? You could teach anger management better than I can. You know all of this stuff." And, and the young man said, and this is actually a true story, he said, "Oh, I can use my anger management skills anytime except when I'm angry."
Keith Sutton, Psy.D: (31:54)
Yeah.
Julian Ford, PhD: (31:54)
So what I was thinking, as I was talking with this young man, was: okay, how am I going to be able to show him what he's capable of? I'm not going to try to teach him something that he then has to layer onto what he's already doing, because he's already got his way of approaching things — he just doesn't know what to do when that alarm gets triggered. A lot of the time when we talked, he was on his cell phone, paying very little attention to me, and I just tried to be patient and not go too deep into my fear that I was making no difference and doing nothing about it — which were clearly strong fears, though. But at one point he brought in his phone and said, "I want you to watch this." He had filmed a couple of kids at his school fighting.
Julian Ford, PhD: (32:45)
And I said, "You know, I'm not that comfortable watching a film of your classmates fighting." He said, "No, no, you've got to see this. You've got to see this." So I was thinking, "Well, okay, he's telling me something here. What is he telling me?" So I said, "All right, I'll watch this, but I'm going to watch it only to see your camera technique. I want to see how you made choices about what to film and whatnot." And it turned out that he would maneuver all around these kids who were fighting to get different angles, and then he did a post-fight interview with a couple of them. None of which was easy to see or think about. But what I learned from that, and was able to tell him, was that he had the ability to see things in a way that most people don't.
Julian Ford, PhD: (34:30)
And I could see that was a skill he had been using through a series of placements, foster homes, and residential treatment programs. He had a way of seeing when he needed to get out, and he would then do something to get himself sent to another setting. I suggested to him that maybe this was actually a really important ability he had, that he was using it to kind of fend off problems — and I understood that he needed to do that — but this might be an ability he had that not everybody has, that could actually be really important. He sort of said, "I don't know, I don't know," but I could see he took a moment, and it was a seed that was planted.So that's what I think about in doing therapy. Sometimes people are just really able to talk through things — they're just primed to discover more about themselves, and that's wonderful. Other times, it's not that easy. What I've found is that hopefully what I can do is show them something about themselves that they can take with them, and potentially be able to use in situations that come up, in a way that is not just to survive. And that's probably not the explanation you were expecting, but that's okay.
Keith Sutton, Psy.D: (34:30)
That's very helpful. I like what you're saying — that you're kind of tailoring it to the client specifically, and looking at where their inroad is, whether it's the emotions or the core beliefs. And I wanted to go to this piece you mentioned about who they are as a person. I know one of the aspects of CPTSD is one's sense of self. The way I've thought about it is that, oftentimes, growing up in an invalidating environment — say the parent smacks a kid, the kid starts crying, and the parent says, "Why are you crying?" — the child begins to question their own sense of reality, and starts basing what's happening on others' reactions, which can lead to codependency sometimes.
Keith Sutton, Psy.D: (36:00)
If they're happy with me, I'm good. If they're unhappy with me, I'm bad. That sense of self really rises and falls with what's happening in the circumstance or the moment, rather than having a more consistent sense of self. So I'm hearing that there's a big aspect of this — getting to know one's self and one's values. It reminds me of Acceptance and Commitment Therapy — connecting to those values, and not bouncing around depending on what's happening in the situation, but really moving toward those values despite discomfort or avoidance.
Julian Ford, PhD: (36:39)
Exactly. You've described it perfectly — as basic as that may seem, I think it's really complex and challenging for most of us to step back and actually consider: okay, who am I as a person? Not so much what I've been told about who I am, or how people treat me — even though those are important influences — but who do I know myself to be, through my own eyes? And that, of course, isn't just a matter of philosophical sitting back and pondering. It's very much something we're all trying to figure out every moment of every day: who am I in this situation? What do I believe in? What are the values that can guide me through this challenging situation, whether it's an ordinary day-to-day situation or a traumatic one?
Julian Ford, PhD: (37:42)
And the idea is that people who've experienced trauma so often — whether it's literally a DSM-5 traumatic stressor, or a validating environment, as you were describing, which is also equally traumatic, just in a different way — whatever that individual has experienced has shown them a view of themselves as shattered, fragmented, messed up, weak --
Julian Ford, PhD: (38:16)
Insufficient, unworthy, and, complex PTSD, that's really a core aspect that the sense of that I'm just worthless or I'm a failure.
Keith Sutton, Psy.D: (38:26)
Toxic change.
Julian Ford, PhD: (38:27)
Or that I'm so damaged that I can never be fixed. So again, rather than saying, "Well, you're a whole person, and we're going to make sure you think of yourself as somebody who is entirely worthy because you are human" — of course that's true — I think people who've experienced trauma and invalidation, or both, need to be able to discover for themselves who they are. And that's where I think we as therapists are capable of being really wonderful mirrors, because we can see, in experiences they might think of as entire failures, how they actually thought it through, and within the limits of what was possible in that situation, made choices that were actually very wise. And they also may have had to make choices, or deal with dilemmas, where they couldn't be entirely consistent with their core values.
Julian Ford, PhD: (39:27)
And that the courage to face that, and to nevertheless deal with those situations, is a mark of who they are as a person — not the fact that they couldn't perfectly live their values. So I find that many times the clients I've worked with over many years — sometimes for many years — will often say, "Oh, there you go again, trying to make me feel good about myself. Trying to tell me something that's good about me. I get kind of tired of you always seeing something good in what I was able to do." And of course, I don't just see something good, but I always think it's important to find within the experience, whether it's a current stressor or a past trauma experience, ways in which that person was able to do things they didn't realize reflect who they are as a person --
Julian Ford, PhD: (40:28)
In spite of the fact that they may not have been able to control much of the situation, and may have been deeply hurt by what happened as well. So that's why, my way of thinking about this, it's not as simple as just giving people positive reinforcement or praise. It's very much helping them discover, in their experiences, who they are in a way they hadn't realized. So if they have multiple self-states, as you were describing — as in dissociative identity disorder, or the Internal Family Systems approach — those self-states represent aspects of the individual, and that's how I think it's really important to approach people. I don't specifically help them identify different self-states, but if they do that spontaneously, and see themselves or experience themselves in very different ways, what I see as my fundamental responsibility is to help them see the person who's in there across all of those self-states.
Keith Sutton, Psy.D: (41:39)
Yeah.
Julian Ford, PhD: (41:40)
And of course, each of us is going to be very different depending on the situation. Sometimes we're going to be angry and fight back. Sometimes we're going to run the heck away. Sometimes we're going to stand our ground. Sometimes we're going to protect. Sometimes we'll take care of others, even at the cost of ourselves. And again, it's not to judge any one of those reactions, but more to see what's the core value in all of that. Is it a sense of needing to be loyal to those who trust you? Needing to be honest, even at times when honesty may have a great price? Is it a sense of needing to treat others the way you would want to be treated — the golden rule, as simple as that may seem?
Keith Sutton, Psy.D: (42:24)
Yeah. Yeah.
Julian Ford, PhD: (42:25)
So finding that core self that runs through and is really focused, largely, on core values and core goals in life — that I see as the ultimate challenge for all of us, whether we're doing EMDR, cognitive processing therapy, prolonged exposure, experiential therapy, or psychodynamic therapy. Each of those has different ways of helping people begin to see themselves more fully. And I just think it's really crucial that, regardless of the therapy modality, we're always, as therapists, thinking about: what am I showing this person about who they are?
Keith Sutton, Psy.D: (43:08)
Sure. Sure.
Julian Ford, PhD: (43:09)
Not proving to them that they're better than they think they are, but showing them who they are and in a way that reflects their, their core self --which is intact even if they feel very shattered.
Keith Sutton, Psy.D: (43:22)
So you've kind of got that radar detector out for those values that are inherent within what you're hearing or seeing — those trauma stories — really seeing those within, to be able to help reflect those to the clients, for them to see those pieces that are there.
Julian Ford, PhD: (43:44)
Yes.
Keith Sutton, Psy.D: (43:45)
Yeah, that might be covered up by all the other stuff, the trauma, the reactivity, the, you know, all those kind--
Julian Ford, PhD: (43:52)
Well, and gosh, people have complex lives, especially if they've experienced trauma. So there are so many complexities, and it's really like a smoke screen. It's hard for anybody to see through that. But I think we as therapists have that opportunity to do that, and to help our clients begin to do that too.
Keith Sutton, Psy.D: (44:14)
Sure. Now, I'd like to touch on, if we could go back to the piece around missing the diagnosis of trauma with children, and potentially having an ODD or ADHD diagnosis instead. What do you make of that, or what are your thoughts on why that might happen? I think that's oftentimes the fear of a therapist who doesn't understand some of those diagnoses as well — that the label's just going to get slapped onto a kid, and you're going to miss what's really underneath it. And that happens. And I think sometimes people might go to the other extreme, where they become more reluctant to give some of those diagnoses, for fear of not really addressing what the core pieces are, or so on.
Keith Sutton, Psy.D: (45:03)
Yeah, what are your thoughts or what through the research were you all finding around why those misdiagnoses were happening? I know you alluded to it earlier a little bit too, but yeah.
Julian Ford, PhD: (45:13)
Well, I think it's an "and," not an "or." So in so many cases, kids will be legitimately diagnosed with ADHD or ODD because they are experiencing difficulties with attention, hyperactivity, or oppositionality, and just kind of aggression, or at least resistant behavior. So those are real, and I think that's why it's really important in treatment to have access to modalities — whether they're pharmacological or more behavioral, parent, and behavior management approaches — to help kids who have attentional difficulties with executive function, working memory, and processing. So all of that is very important. And then, in addition, I think what we can add to that is: if we know from a child or from their caregivers that this particular child has experienced traumatic threats or traumatic experiences of any kind, and if some of their difficulties with attention, arousal, behavior, and attitude are fairly reliably triggered in certain situations, by certain kinds of interactions, that are then either likely or potentially related to experiences that have been very stressful or even traumatic for that kid --
Julian Ford, PhD: (46:52)
That if we can take that into account, you don't necessarily have to do trauma-focused cognitive behavioral therapy. You can — and even my wonderful colleagues who do TF-CBT, and I do it at times as well, although I'm not as well-trained as I should be — it's not always the case that a trauma narrative is done in trauma-focused CBT. There are many other ways in which the child and their caregivers are helped to understand the reactions as ways of reacting that are exactly what I'm talking about, because of that kind of internal alarm, and ways they can then turn that alarm down, so that it's not just ready to go off and interfering with concentration or attention, or triggering hyperarousal or reactive behavior. So I think the important thing we've figured out is: if you're working with a kid who meets criteria for one of those disruptive behavior disorders --
Julian Ford, PhD: (47:57)
That if you also know enough about their life story, and are being careful in doing a kind of behavior-analytic approach — looking at what the discriminative stimuli are that are associated with the problem behavior, and the consequences that may then unfortunately reinforce that behavior — if you look at that very carefully, you may find that for many of these kids, some of those kinds of triggering and reinforcing situations are related to aspects of the trauma they've experienced. It wouldn't necessarily be exactly the same thing — it could be just a reminder of something similar, even as subtle as somebody who has a certain facial expression, that then triggers a reaction. Then it becomes possible to help that kid and the caregivers recognize, "Okay, so these are reactions that make sense, given that you've been through something that was very stressful."
Julian Ford, PhD: (49:05)
"And so let's plan for how you can handle those situations, or we can help you in those situations, or prevent those kinds of situations." And that, in that sense, is where it becomes trauma-informed therapy, whether or not it's trauma-focused specifically. And that's what I think can be a really big advantage, because I meet with our child psychiatry fellows who are working with kids who've been through all kinds of really tough experiences, and have pretty severe psychiatric problems. And every time we talk about a case, we talk about that child's or teenager's life — what they've been through, the good and the bad — and as we begin to put together a picture of what that child's life has been like and what they've learned, it informs the fellow about how they can approach the treatment in a way that then reduces some of the trauma reminders--
Julian Ford, PhD: (50:04)
Or helps the child, teenager, or their parent or caregiver respond when there is that kind of reminder, and recognize that once you know how to respond to it, it becomes less likely to be triggering. That's the benefit I can see. So again, if there's no trauma history, if there's no connection to past experiences, then don't add that on.
Keith Sutton, Psy.D: (50:32)
Well, and I think it's so difficult because there's such an overlap — kids with ADHD have higher levels of PTSD, because there's an interplay around symptoms, heritability, and parent symptoms, as well as with oppositional defiant disorder. There are many, many roads that lead to Rome on that. I don't really like the oppositional defiant disorder diagnosis, because it's not something that's within the child, but I do like it in that it's one of the only systemic diagnoses in the DSM, looking at the pattern of interactions that might be happening between parent and child, or parent, child, and teacher, or whatever it might be. But yeah, there's often that overlap, and I think a lot of therapists get caught up on: is it ADHD, is it trauma? And really, oftentimes, it's for the psychiatrist to determine what appropriate medication might be, but as a therapist, you're still going to work with the kid and the parent, helping those things be less volatile and more warm and connected, as well as helping with dysregulation — and maybe that is related to the trauma, so you do more trauma work, or maybe that's just working on the dysregulation anyway.
Keith Sutton, Psy.D: (51:47)
So those are, I think big pieces.
Julian Ford, PhD: (51:50)
Exactly. And I'm glad you mentioned the systemic approach, because my original training was as a family therapist — so I'm remiss in not having factored that in, helping the child or adult, and other members of their family, figure out how their reactions are interwoven and affecting one another, and then helping them begin to discover some of the shared core values that they have. That's what I learned in my family therapy training 50 years ago. (laughs) If we can find some shared core values, then we have the beginnings of a way to bridge the gap that can grow up between people, or the conflict that can tear them apart.
Keith Sutton, Psy.D: (52:44)
Yeah, definitely. Well, that's great. So can you tell a little bit about, like, how folks can learn more about the approach that you have developed and the target model? And is there, I think you've written some books. Is there trainings? There's research articles.
Julian Ford, PhD: (53:03)
Well, there are some of all of that. But to keep it simple, I will suggest there are two websites. I'm very fortunate to have been able to start, and now continue, two centers within what's called the National Child Traumatic Stress Network — that's a federally funded set of centers all across the country. The two I've been involved with have websites, and the best place to get information on both the TARGET model, on developmental trauma, and complex PTSD would be to go to — so first is the Center for Trauma Recovery and Juvenile Justic
Julian Ford, PhD: (53:51)
And the second is the Center for the Treatment of Developmental Trauma Disorders. And I will be glad to--I'll send you those websites.
Keith Sutton, Psy.D: (54:01)
Perfect. And I'll link them in the bio on the website too, because that would be a great resource for folks — because this is such an important area, and the research I was originally drawn to is what happens when it gets missed, or gets mixed up, and maybe the therapist is sometimes missing pieces of those puzzles that are really important. And I think for many of us — I know I didn't really get the depth of training to really understand CPTSD until I was looking at my own caseload, and at the folks I'd been working with the longest who hadn't graduated, and I noticed the common thread that ran through was CPTSD. So I think it's such an important area for clinicians to get trained in, because if you don't really understand it or wrap your mind around it, you can miss that really important aspect.
Julian Ford, PhD: (54:55)
If you don't know to look for it, you'll never see it.
Keith Sutton, Psy.D: (54:58)
Exactly. Right.
Julian Ford, PhD: (54:59)
And if you do look for it, you won't always see it.
Keith Sutton, Psy.D: (55:03)
Yeah, yeah. Well, thank you so much. I really appreciate you taking the time, I really appreciate it. Thank you.
Julian Ford, PhD: (55:10)
Thank you, Keith. It's been a real pleasure talking with you.
Keith Sutton, Psy.D: (55:13)
Yeah. Bye-bye. Thank you for joining us today. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults with our licensed, experienced therapists — in person in the Bay Area or throughout California online — and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships, and low-fee treatment through our nonprofit, Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need, and training in evidence-based treatments, you can donate by going to BACC's website at sf-bacc.org. BACC is a 501(c)(3) nonprofit, so all donations are tax-deductible. Also, we really appreciate your feedback.
Keith Sutton, Psy.D: (56:20)
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