In a special Q&A, forensic psychologist and crisis expert Paula A. Madrid, PsyD, talks with Psycom Pro about how the COVID pandemic has widened the door of trauma for so many, and how clinicians can tweak their trauma-informed care approaches going forward. Dr. Madrid is a member of the Psycom Pro Editorial Advisory Board. Q&A reported by Executive Editor Angie Drakulich. An edited transcript follows; you can also listen to the full audio below.

Psycom Pro: You’ve worked on patient cases of all ages and in all types of conflicts, including in the aftermath of terrorist campaigns, such as the Madrid train bombings in Spain, and in natural disasters such as post-hurricane relief in the United States. We’re in a different type of dramatic conflict right now, the COVID pandemic. How does what we’re seeing in the multiplying rates of anxiety and depression today compare to what you’ve seen in your prior work?

Dr. Madrid: It is indeed a very different type of situation at this point in time. The world has grappled with a pandemic for more than six months. For many, it has really involved daily “trauma” to use the word in a pretty informal way, which is a significant stressor. People are afraid of becoming infected. There have been many financial challenges. People have faced tremendous uncertainty in many aspects of their lives.

And something that has also greatly impacted people, especially those I talk to, is the lack of control, not knowing what’s going to happen, not knowing how to deal with a lot of what they are facing. This is a very different type of stressor that has brought on new clinical challenges.

 

Defining Trauma

Psycom Pro: Let’s talk a bit about what the word “trauma” means and why the pandemic and may be widening that definition.

Dr. Madrid. In everyday language, trauma means a highly stressful event that impacts someone. The key to understanding traumatic events is that it needs to refer to extreme stress that overwhelms a person’s ability to cope. It’s important to keep in mind that trauma is a very subjective experience – we cannot simply say ‘You’re traumatized. You’ve been through something traumatic.’ It is up to the person.

In fact, psychologist John Allen, who wrote an amazing guide to self-understanding, discusses the fact that there are two components of a traumatic experience: objective and subjective.

He indicates that it is the subjective experience of the objective event that actually constitutes the trauma. That’s important to keep in mind.

It’s very different to say “trauma” compared to “PTSD” – that’s a whole different conversation. But it’s important to keep in mind that we’re talking about extremely stressful events here.

Psycom Pro: You mentioned objective and subjective – people dealing with trauma, for the most part, may deal with it their entire lives. Much of your work centers around consulting on cases and treatment plans. So when you’re reviewing trauma cases, especially with the risk of COVID as a traumatic impact, how are you approaching those cases? Do you consider prior trauma patients to be more vulnerable to relapse right now?

Dr. Madrid: Yes. So what we know about trauma is that there are several risk factors that we consider to be vulnerability factors and a very key one is the experience of a prior traumatic event. Relapse is possible, especially if the person has not worked through it or gotten treatment.

It’s also important to keep in mind that they are different types of trauma. With acute trauma, it’s perhaps a single very, very stressful event. Most people come out okay and, within a couple of weeks, learn to manage by integrating the experience into their life.

Others experience chronic trauma, which refers to those who have experienced repeated or long exposure to highly stressful events. Unfortunately because of COVID, a lot of folks are dealing with chronic trauma now. Fear of the unknown is happening now, which can compound a person’s reaction.

And there is complex trauma when a person has lived through many different traumatic events. So for instance, prior victims are survivors of some type of trauma, and now, in dealing with COVID, whether they got infected or have a relative in the hospital or who passed away – this experience can take a new toll on their functioning. (More on COVID’s impact on general mental health from Psych Congress 2020)

 

What’s Coming to Clinicians as Mental Health Crises Grow

Dr. Madrid: Data indicate that mental health issues are on the rise in the general population. And of course, those of us who are clinicians are saying, ‘Wow, what’s coming our way?’ But prior to that, there were already increases. A survey conducted, for example, indicated that even prior to COVID, more than 60% of Americans reported feeling lonely. I can only imagine what their current experience must be like after many months of isolation.

While not everyone’s experience has been the same, in general, we can make a statement that most people have engaged in some level of social distancing. And so, loneliness is only likely to increase.

Another survey by the CDC of over 5,000 Americans showed that over 40% of responders reported an adverse mental health or behavioral health condition. There’s an increase in depression and domestic violence and anxiety. There are just too many stressors. And I think what makes it much more challenging is that people are not really sure or capable of coping the way they used to.

 

Coping – Does Its Premise Work in a Pandemic?

Psycom Pro: Can you expand on this?

Dr. Madrid: The coping skills that were available to most of us have been taken away or made much more challenging.

People just don’t feel comfortable going out. The ability to see friends and family has been diminished greatly. This will greatly impact people’s mental health, especially those with children. And for many, this may create the perfect storm. That’s something that we need to be thinking about and doing something about.

 

Assessing Children and Adolescents: Asking the Right Questions

Psycom Pro: There’s definitely so much going on and it doesn’t help that there’s a reported psychiatry shortage in the US. Demand for mental health care is only going to grow.

You mentioned children and how different experiences of trauma affect people differently. Let’s shift gears and talk about children and adolescents. They’re facing a lot of anxiety or new phobias, perhaps for the first time with the pandemic. So clinically, what questions should providers be asking young patients right now, as well as their parents or caregivers, to help move them in the right direction?

Dr. Madrid: At this point in time, we don’t really have a good sense of what the overall impact of COVID-19 will be on the mental health of children and adolescents. We will learn more over the years, but we can look for red flags – even though it is tricky. The way we’re living life today makes it very challenging to distinguish and perhaps diagnose or rule out certain things.

Normally, we would look at changes in everyday behavior and mood, such as the inability to socialize or desire to socialize. We typically look at extreme, or even moderate changes in the person’s way of behaving. But how can we really measure this as everyone has started to behave differently?

What we can do is have a longer conversation than usual, even though many clinicians are pressed for time. In primary care, there are a few questions medical professionals go through as part of a well-visit or even a sick visit. Expanding on those questions will be crucial, including asking parents if their child’s personality seems different.

As an example, a change may be that the child does not appear to be as interested in socializing as before, but this could be because the parent doesn’t want or allow the child to go out [due to the risk of exposure]. So getting at the details around these questions will be really important as will paying attention to children and adolescents who are isolating.

I have had in the last month one adolescent patient in mind who just doesn’t want to leave their house. It’s pretty problematic because they have the ability to leave the house, they can go to the park, they have options, but they prefer to be in their bedroom. So this is when I know there’s something going on.

At the same time, parents are dealing with a lot of stressors. So provider conversations with them about family stressors and home limitations are important as well. Whatever parents are concerned about is worthy of notice.

More on secondhand trauma and children on our Psycom consumer site. Plus see Dr. Madrid’s profile in the NY Times regarding her family choices during COVID.

 

New Somatic Issues in Children and Adolescents

Dr. Madrid: It’s also important to understand increased somatic complaints. In some cultures, there are not many conversations about depression or anxiety, or even insomnia. But maybe a child is saying they have a headache or stomach pain. Understanding that many somatic complaints are the result of psychological phenomena is key, especially when it leads to school refusal.

In my experience, children often say they don’t like school, but they actually do want to learn. They want to connect with their peers, even if it’s online, so I think extreme school refusal from a child is something to watch for, especially if it’s a significant change from prior behavior.

Other things to look for are children having more nightmares, eating much more than normal, gaining or losing a significant amount of weight, sleeping too little or too much.

There’s a 15-year-old I’m working with who is now sleeping about 17 hours a day. Another woman I spoke with is 18-years-old and she gained 70 pounds in the last four months. It’s easy to catch onto these signs, but we also have to keep asking questions.

Teletherapy: Visual (and Verbal) Cues Can Make the Difference

Psycom Pro: Many clinicians are doing teletherapy visits these days. Are there certain visual things providers can look for right now beyond asking these important questions?

Dr. Madrid: It is much more challenging to do any type of intervention or conversation on a screen. For the most part, people report feeling comfortable and there’s a level of extra safety that is added, and so that actually increases therapy satisfaction and can add to the healing process.

But as a therapist and as a clinician, we rely heavily on body language. And it’s not just the body language of the client’s face – you’re really are looking at the way the person sits, the orientation of their feet, their shoulders’ alignment with their torso. When you’re online, this is not as easy to see. I had a young patient recently who would only show me half of his face, so I had to say, “I really need to see a little bit more, tell me why you’re only showing part of your face…’

You can dig into these questions and talk about what works for each patient.

At the same time, the absence of the ability to see the person’s full body forces us to engage in a different way.  We can actually gain quite a bit by increasing patients’ resiliency and verbal skills. This can be a teachable moment! One life skill we should all be learning is to verbalize our feelings, to be more detailed about how we explain what we feel.

So I might say, ‘I hear you’re saying you’re tired. I just want to understand it much more. How do you feel it? What are you thinking when you’re feeling tired..?’

So teletherapy in many ways allows for a deeper conversation.

I have seen this with PTSD and trauma patients, in particular, who are often more avoidant and anxious. As a therapist, we are having to challenge them to find the right language to put to their feelings. And this is a humongous positive difference.

 

Additional Crucial Asks

Dr. Madrid: Finally, pay attention to the client’s background. Is the person always in their pajamas? Is there clutter visible? I supervise a young clinician who told me that her patient had knives on a table in the background and she was too afraid to ask the patient about them. But we need to ask those questions. So whatever curiosity or reaction you have, ask.  Because it’s clearly important.

Keep in mind what a depressed person looks like. And ask questions if you feel the person might be in trouble. You need to ask, ‘Are you having thoughts about hurting yourself.’ It’s OK for that to be your first question of a session – don’t wait to the middle or end when you are running out of time, which is something I hear from many of my friends who are clinicians.  The presence of any type of self-injurious behavior is important to keep in mind for our welfare and for theirs

And don’t be afraid to ask a patient to pull their screen back and show you their abdomen when appropriate. We do this in practice to see if proper pragmatic breathing is happening. Some people may not be inclined ethically, but it is what we do in person. When teaching breathing techniques, we even show our patients our own abdomens to show what happens when you inhale, exhale.

You know, we need to be comfortable. We need to model that and lots of wonderful things will happen.

 

Paula A. Madrid, PsyDJust Getting Through the Clinical Day

Psycom Pro: Before we end, I want to ask you a more personal question for Psycom Pro’s Practice Essentials feature. Is there one thing you’re doing right now that gets you through your clinical day?

Dr. Madrid: So, I’m working from home and I do have a child in virtual school. What helps me is to take a break in between activities. I always have 10 to 15 minutes in between every single thing I do so that I can check in with my kid so that I can go outside and look at the garden.

I have decorating magazines that I keep with me all time that I love. Just looking at something aesthetically beautiful helps me.

I’ve also started to take French lessons. It’s amazing. It just takes me to a different world. It makes me happy that I’m doing something for myself and I’m pretty proud of it. And so I think these things together increase my self-esteem and satisfaction with my life. And they make me a better therapist.

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Last Updated: Nov 19, 2020