PTSD Signs, Symptoms And Support

PTSD Signs, Symptoms And Support: Dr. Kelly Clarke & Psychologist Craig Martynuck

Mental Health Matters in Edmonton | PTSD: More Than Just Trauma

Kelly: Hi there Kelly Clark here, talking about mental health matters in Edmonton. Today I’m with Craig Martin. He’s a psychologist working in Ontario; he’s been practicing there for some years. Today we’re going to be talking about PTSD, and he’s going to tell us a little bit about that condition and other things within his practice. So I’m going to just open that up with that: Craig, can you tell us a little bit about your background and what kind of population you work with?

Craig: Yeah, well, thank you for having me, Kelly. Yeah, my background comes from—comes from a place where I’ve been a psychologist for about a decade now. But leading up to that, I feel like I have some—some connection with the—with this PTSD. First responders: my practice, for the most part now, deals with first responders, anxiety, depression, PTSD typically related to their job. And so, you know, I believe I’m well suited and have a lot of personal experience.

I have worked as a first responder: I’m a volunteer firefighter as well as a search and rescue volunteer and Coast Guard auxiliary. I’ve been married for 28 years, and not to say that that’s trauma, but my wife was a first responder; my four kids are first responders. And so the population that I work with has, for the most part, primarily now police, fire departments, paramedics, dispatchers, corrections officers, customs agents. And so there’s a—there’s a lot of carryover both in my personal life and—and my experiences with this population.

Youth With Past and Complex Trauma

You and I also worked years ago; I first met Craig when we were working front line with youth who had a lot of emotional challenges related to past traumas. And so we—we had some experience, I think, in working with kids that had quite a bit of—quite a bit of trauma, complex trauma. So you’ve got that background as well.

Kelly: Yeah, that’s interesting. Part, I think, that is one area probably does not get recognized as creating symptoms for PTSD: working with highly dysregulated young people. There is that sense of both you’re trying to connect with them and help them, but also because of their struggles they put you at risk. And being a young person, they’re not considered a threat, but they very much are just by the fact that, you know, they can’t manage themselves very well.

Craig: Mhm.

Kelly: Yeah. Lots going on for those young people. But your current population you’re working with is mostly adults?

Craig: Yes: firefighters, police officers, first responders.

Kelly: Yeah. And so, with that population, what would you say is—it is about the first responder population that puts them at risk?

Our Bodies Are Designed to Protect Ourselves

Craig: Yeah, well, you know, for the most part our body is designed—and so is our common sense—to run away from danger. Like, our natural instincts, the way our body is wired is that we’re to protect ourselves; we’re made to survive. So we’ve got a lot of natural and biological and psychological constructs in place that say, “Hey, you need to take care of yourself.” So typically that means move away from anything that can cause you harm. The challenge with first responders is their job is—and they’ve made a commitment—is that they actually run towards harm. So the very nature of their body and their psychology is going against what they’re doing.

Kelly: Mhm.

Miswiring Against Mechanisms for Survival

Craig: So it causes, at some level, a miswiring or rewiring about and against your natural mechanisms for survival. And so a part of that is the fact that, you know, they—they are running towards danger when everybody else is running away. They’re also having to go opposite the way the body’s wired.

So typically when people undergo a stressful situation, they can’t think very clearly, and their body wants to take off on them, and their emotions want to take off on them. And being a first responder means I literally have to be—and do exactly—the opposite of what everybody else is doing. I have to think clearly when everybody else is not thinking very clearly. My emotions have to be almost paused or turned off, because I can’t get caught up in everybody’s emotions.

When there’s an emergency, a crisis, everybody starts to get anxious and that triggers people. I also have to be at a place where my problem-solving skills—I have to be well trained to deal with situations that most people are not trained for. So even that part of me, I have to be able to pull up skills that I’ve trained for in order to keep people safe. And so all of that almost is doing the exact opposite of how I’m wired to do it. So, you do that for a long period of time under extreme situations, it’s almost inevitably going to cause some effects on you that aren’t positive.

Kelly: It takes its toll because you’re going against your body’s natural inclination.

What Does PTSD Look Like?

Craig: Yeah. So what does PTSD look like? What are some of the symptoms you’re experiencing in that population of individuals that, you know, do that great job?

Kelly: Yeah.

Craig: Well, you know, at some level it differs depending upon what job you do. So at some level police and their activities will be different from dispatchers and different from paramedics and the exposures that they have, what they’re required to do. But the interesting part is that PTSD is kind of a clinical diagnosis according to the DSM that says in order to have the title or the diagnosis PTSD, there has to be certain criteria that’s met.

And it’s broken up into about six categories, and in each of them you have to show—show, you know, symptoms in each of these. The reality is that the effects of trauma are cumulative and they’re also almost on a spectrum. They start creeping in subtly at first, and potentially they will last for a while and then go away, but slowly but surely they start to increase both in intensity and frequency and the amount of space that they take up in your life.

Stress Disorder and Anxiety

So from a clinical point of view where a person crosses a threshold of just having a stress disorder or anxiety situation into the level of PTSD, you’re going to see symptoms like sleep dysregulation: having a hard time falling asleep or else waking up in the middle of the night, typically around 3:00, tends to be a magic number. You might have work-related dreams and/or flashbacks and/or nightmares. So there’s kind of a retelling of the things that you’ve been experiencing. There’s hypervigilance, which says, “My job is to keep other people safe from danger,” and so my nervous system starts to get wired to say, “I start looking for danger even when I’m not at work.”

And that will show up in simple things like having an arousal overreaction: somebody can call your name and you can jump out of your chair, or you walk into a room and you instantly want to take a seat such that you’ve got your back so nobody can sneak up on you; you don’t like crowds because there’s too much stimulation: all sorts of ways it says, “I am expecting danger even when it’s not reasonable to expect it,” and they call that hypervigilance.

Mood Dysregulation

Mood dysregulation is a big one, which says my moods aren’t typically very stable and/or they’re overactive. And so my nervous system is wired higher than it should be. Also, in a crisis, you typically lose the ability to be in a good mood.

So if my mind and my nervous system are stuck either getting ready for a crisis or believing that the crisis is still on, I lose the ability to have joy or to have happiness, to smile, to have a sense of humor. I become pretty somber; I become pretty reactive; might even be considered, you know, to people who know me, cranky—and that’s on the lower end of the scale. Some people start to have quite significant anger outbursts, which are not characteristic for them.

Cognitive Impairments

Cognitive impairments is another one: I can’t think straight. Again, in a crisis, when there’s so much information happening, typically you zoom in on one issue. Well, if you’re not actually in a crisis, your brain is still not able to be flexible enough to think clearly and integrate information that I need for daily living.

So my memory starts to go; my focus is gone. I get to the grocery store and I can’t remember the three things that I’m supposed to pick up, but I can tell you the license plates of the cars in the parking lot because at some level, maybe if I’m a police officer, that represents my way of operating and keeping a situation safe.

Emotional numbing is kind of the opposite, which means being in a stressful situation: in order to keep my mind, you know, solid, I learn to turn my emotions off. And that’s effective for me in a crisis situation because I don’t want to overreact and feed into somebody else’s stress response, so I tend to turn mine off.

Problem with that is that I become very accustomed to not having emotions, and so that works great when you’re in a crisis but it does not work well when you come home and you lose the ability to connect with your spouse or your kids or your neighbor. It’s like if you want to put out a fire, you put a wet blanket out on it; it puts it out for all situations.

So I could literally not feel anything, and that’s one of the key things: people say, “Nothing upsets me anymore because I’m so used to seeing such incredible situations that most people don’t see; I’ve stopped reacting to everything.” And that personal disconnectedness too: they can’t feel things, or they at least stave that off, so they’re disconnected from their own selves, their own emotion, in addition to the community and relationships that are important to them.

Social Distancing and Disconnection

And that leads into social distancing, meaning I first start moving away from people because people are unpredictable, and I deal with all sorts of unpredictable situations in my job. It also takes emotional energy and positive emotional energy to be with people that you enjoy, and if I don’t have it—that I’ve turned it off—I will feel very alienated and feel like I don’t belong around people anymore.

So they start to isolate; they start to isolate and alienate, as well as they start to have a sense that nobody else understands me, nobody sees what I go through every day.

And so I lose my friends because I can’t talk about my job—nobody would get it. You know, there’s confidentiality issues; there’s also the sense that the job that I do is, you know, sometimes I do things that I’m not proud of and I wouldn’t want to share that with other people. And so it leads to a person feeling very disconnected. Or if they are connected, they only can connect with their co-workers because they all kind of share similar experiences, and that normalizes it.

And that’s a challenge: you don’t even recognize that you are moving away from who you originally are because there’s other people giving you feedback that says, “This is normal,” and you lose the ability to compare yourself against the rest of the population. So your symptoms actually can become quite severe and you not know it because you’ll see it in your co-workers and say, “Well, that’s me.” Whether that’s addictions issues, whether that’s dark humor, which says we laugh about things that the rest of the population would think, “Oh, that’s inappropriate or disgusting.” And to us that’s kind of the only way we know how to let off steam.

I know an inspector in the Edmonton Police Service who, one of the things he would keep saying—it’s kind of like a litmus test that he would say to his colleagues and people that he is supervising—is, “Make sure that you keep your everyday friends, not just police friends.” And he thought that when you depart from that too much it was a bad indicator of mental health.

Kelly: Mhm.

Craig: When I have chatted and done treatment with particularly police, that is the first place that we look at: where they start to lose their sense of what was holding them in their space that they started with. Policing and first responding is its own community with its own belief systems, its own culture. At some level, to be fully integrated into first responding, there’s a sense that I have to move away from the world that I came from in order to both learn and be accepted and to be successful.

And that often becomes the first place that we start the treatment process: how do we connect back with the strengths and supports you had before you started to get in trouble? You know, and that’s like, “Wow, I haven’t talked to my civilian friends in like 10 years,” you know, “and I don’t even know if they probably don’t want to hang around with me.” At some level we start to project and say, “Oh, they probably don’t want to hang around with me; I haven’t chatted with them,” when I’m the one that has moved away from them, if I’m the first responder.

Kelly: Yeah.

Depression a Symptom of Trauma

Craig: So sometimes challenging belief systems like that. Also, some of the effects or the symptoms of trauma is, you know, depression. That’s one of the key things that I’m exposed to: so many things and my nervous system and my emotional system are just so fatigued with so many dark things I’ve been through, and I start to feel hopeless and helpless and like I don’t have any joy in my life.

I stop—I lose the interests that I’ve had, my hobbies, the things I used to enjoy that, you know, were ways for my brain to switch channels from all the heavy stuff that I carry. I don’t even feel like I have enough energy for that anymore. And so I literally start losing connections with all the things that were part of my life and kept me healthy before all this stuff started. And that combination of shift work and that insular community—they feel isolated.

Kelly: Yes.

Craig: Yeah. One of the key components that a lot of the police officers I talk to say is that nobody understands our world; we’re invisible essentially. We deal only with people on their worst days, and a component of the community we’re disrespected. Our society has changed in terms of how we consider policing, for sure, in terms of the respect that previously was due in another generation where to be a police officer was highly regarded and highly esteemed.

And tides have changed, and now it’s seen as something that would be not attractive, and a lot of people throw insult and criticism at these men and women that are actually putting their lives on the line. And it feels like such a betrayal of the expectation of how I should be treated: I’m literally putting my life on the line for the community, and people are calling me names, spitting at me, disrespecting me. And so there’s a high sense of both disconnection and a sense of not being appreciated.

And to do all that work, at some level it becomes a community that supports itself because there’s no supports outside of it. And a lot of first responders—like I don’t want to just isolate policing—but certainly that is one of the highest professions that show PTSD symptoms and depression and anxiety and high divorce rates, high addiction rates. There’s all of the bad indicators showing up highest in that and the military.

Kelly: Mhm.

Craig: So with PTSD I think a common association with the condition is that there was some kind of event that precipitated or led to difficulties functioning. So it sounds like you’re also saying, yes, in addition to that, you can ruminate and have dreams and day visions and these kinds of things, it can also be a cumulative effect.

Kelly: Yeah.

The Index Incident

Craig: In fact, they have changed the legislation recently. Previously, it used to be that, “Oh, you have PTSD; tell us the day what happened,” you know, “give us a date, give us an incident, nail it down to one.” They call that the “index incident.” And now they have, based upon some very serious situations that occurred, recognized that it is not a single-event situation that leads to first responders getting in trouble. And so they changed the legislation; they call it presumptive legislation.

If you’re in one of the careers that I had originally identified as a first responder, we’re just going to assume that the exposures you get day in and day out will inevitably lead to your situation. So they have stopped the requirement for demanding, “Give me a date and a time when everything started happening,” because a lot of people say, “Oh, you’re talking about one situation; I can give you 40 of them.

Which one should I pick?” And, “How many assaults? How many incidences of sudden deaths? Which one should I pick if you want me to write one down?” It’s late in the game but I’m thankful it’s there because it really did minimize the work that those people do, where you and I may have an index incident that would say, “Wow, I remember everything about that call or that situation.” As a civilian you know it would burn in our brain.

First responders deal with two or three or four of these index incidents per shift, and so it just becomes normalized when it’s not normal at all. But in order to get through their shift and do their job the way they want to, it does mean I stop recognizing the significance and the severity of the things I’m exposed to—but it still affects me. And there’s a challenge: it kind of goes undercover; I don’t even recognize that I’m getting damaged because I’m expected to do it.

The culture that I grew up in or that I work in is such that everybody’s been through it, and so there’s an expectation that nobody’s going to have an effect. As well as the whole culture and belief systems regarding mental health in our community at large, but specifically in first responders, has been largely ignored or minimized or even mocked.

So if you’re a person that prides yourself on professionalism and doing your job well and reputation and being seen as competent in your job, for the most part you’re not going to say anything even when things start to go offline. “I don’t want to be accused of being the weak link at work. I don’t want to go off work with WSIB. I don’t want to admit to myself that I’m getting in trouble.” So there’s barriers attached to the mental health component for first responders. It is slowly being addressed, but it’s still pretty predominant, and so there’s lots of areas that need to grow slowly but surely we’re moving there.

What Precipitates the PTSD

Kelly: Mhm. Yeah. You could just see that it definitely takes a toll, especially on those populations where, say, if I see a patient and they’ve got PTSD symptoms, we’ll look at what precipitated the event. But when you’re working in a job when there’s so many of those precipitating events, the accumulation really takes a toll on people.

So, in keeping with that, is there hope for this population? I mean, they’re doing a great job for society; the job is going to take its toll because we’re not geared to be taking that level of emotional difficulties day in and day out without it having some effect on us. So how can we address this? How can we treat these types of conditions?

Craig: Well, a big part of it, I believe, comes first in helping first responders recognize the job that they do and the fact that it is to be expected for the effects to be happening. You know, I try and change the paradigm, or at least how they view themselves, and I say, “You guys are elite athletes. You’re called and can do jobs that most people in the community can’t do.

If we were to put that in sports terms: not everybody can play NHL hockey, not everybody can play NFL or CFL football; the people that make it there are elite. And with that though, they are put in situations where they take a lot of abuse. If you’re on the hockey rink or you’re on the football field and you’re constantly—when you’re working, when you’re good at your job, you’re good at sports—you’re constantly receiving physical impacts, whether it be hockey or football or rugby, you name it.

Your body is taking a beating in you being elite. And so we don’t consider that, “Hey, somebody separates their shoulder or somebody gets a concussion.” We don’t say, “Oh, that person’s weak.” We literally say, “Oh, that person needs care.” And if you’re playing hard, you have physical therapists, you have massage therapists, you have chiropractors. You literally say, “In order to do my job well, I have to take care of myself.”

First Responders Have a Lot of Trauma

That same mentality has to move into the first responder world: the jobs that they do that most of us can’t do have a toll, and it should be an automatic expectation that they would seek help. First of all, that help would be offered—not just after symptoms show up, but, “Hey, you do need this.” This part I call the maintenance program: just like you change your oil in your car. The faster you drive your car, like in the Daytona 500, you go through tires fast, you go through oil fast, you need a pit crew around you to keep you.

First responders run their lives especially when they’re working as if everything is a crisis, as if everything is so urgent. We need to make sure that they are functioning well. So part of that is dispelling the stigma that says mental health is a sign of weakness rather than this is what keeps me strong. Literally flipping that on its head: “Hey, I’m going to”—and I’ve worked with a lot of police officers and first responders that I’ve worked with and have come off work and we’ve kind of rewired their thinking, their belief systems, changed their attitudes.

They have now gone back into their workplace and are the greatest promoters. They become part of the peer support program, and they become the ones dispelling and going to their co-workers because they have eyes that say, “You’re in the same place I was last year or whatever, and I got to recommend that you do something about it. Because if you don’t, if you don’t maintain your car your car breaks down; if you don’t maintain your mental health, you break down.” So better to go for an oil change and rotate your tires rather than breaking down and needing a tow truck when you can’t drive anymore.

First Responders Find It Difficult to Ask for Help

That’s one of the key components: changing how a person sees himself. It’s a very common part of policing that they work out; in fact, they get paid to work out. It’s a very physical job; I wouldn’t want to wrestle most police officers—but any police officers for that matter—it’s a physical job. It’s innate that they know they need to work out. It would be nice that more innate—because it’s a very emotional job too—that they take care of their emotional well-being as well.

I would say for all first responders: they’re literally dealing with people who can’t and are past the point of taking care of themselves; they’re in an emergency and they need somebody else to help them. And so first responders are the ones that say, “I will step out of my comfort zone and I’ll go into your crisis zone and I will help you.” And that’s pretty amazing given how they’re treated, the wages they get, the impact, the price they pay, the price their families pay, their mental health, their physical health.

You know, they’re heroes in my eyes for sure. And as society becomes a little more unwound and unraveled, the traditional pillars that hold our society up are starting to erode a little bit; the pressure on them goes up. We need to be really thinking about how to support them, and for professionals like ourselves: what are the best ways we can keep them healthy and for ones that get in trouble, how can we make them healthy again?

PTSD Affects Your Sleep

Just a couple of things: PTSD touches all areas of your well-being. One of the things typically is how to get sleep regulation. If you’re not sleeping well, your mental health will go down really quickly; your ability to think straight, your ability to make wise decisions. Emotional regulation: often sleep is one of the first and big hitters that you have to look at.

Also mood regulation: giving people skills to deal with the ups and downs of a situation that they’re not in control of and that they’re called to manage. And not having been taught how to communicate in a way that allows you to express and release how you feel in a controlled way—not going passive where you hold it all inside until you feel like you’re going to explode, and conversely the flip side that says, “I let myself explode and I get myself in trouble.” How do you find that middle ground?

Good Nutrition Is Vital

Another one: exercise—your body is one of the key tools that, if you use it properly, can help you manage your mental health. Good nutrition is a huge one, but the exercise part: your body and mind have an inseparable bond and they talk to each other; when one’s off, it takes the other off. So I have to make sure my physical body is well taken care of.

Exercise being a big part: it is a place where I can release a lot of mental stress; I can go and focus and feel power; I can feel my body will take care of me. It also helps me release adrenaline and cortisol—the stress hormones released into my blood—and do it in a way that’s not attached to trauma. So I literally learn to bring my body down to a place where it can start to rest and relax and refresh without using artificial substances. I don’t need alcohol; I don’t need drugs; I literally train my body to release all the nervous energy.

Another one: some of the treatments used because PTSD is a mind-based disorder that shows up in all areas of your body and your life. So there’s a rewiring that has to happen. You’ve got to consider your belief systems will have changed: how you communicate will have changed; how you think about yourself; how you relate to others; even, at some level, how you believe that there is justice in this world.

I see your religious belief systems can be challenged; if you don’t come from a religious background, even your sense of “Is there justice in this world? Is there any sense that there is hope?” Because if you give your best and nothing changes positively, you start to feel very hopeless. That’s one of the key pillars of depression: “I feel like nothing I do can ever make a difference.” At some level, from a survival point, I stop trying. I may not even say I quit trying, but slowly my energy stops showing up and I start feeling like it’s not worth the trouble anymore.

And so I start disconnecting from all areas of my life: family, other things that bring interest and joy. We actually have to say, “Wow, you have changed the way you think about everything. We got to revisit those and say who were you before, because that ultimately is the place where you’re healthy—how do we get back there?” Because in order to survive, especially in the first responder world, you’re focused on disaster and danger and death and all sorts of sadness, and that starts to become an expectation that that’s all the world can offer you.

You start to lose the ability to feel joy and even start to expect trouble all the time. That’s where hypervigilance comes from: “I expect something bad to happen to me all the time.” Well, that’s not realistic, but if your mind thinks it, your body will play it out and it will affect everything in your life.

Cognitive Processing Therapy

They call cognitive processing therapy one of the treatments designed to help a person recognize they have literally shifted their thought patterns about everything and to bring them back in. It’s a slow erosion. I often will talk to police officers: “When you first joined policing, why did you join? What did you expect would happen? How did you treat people?” And they’ll say, “Wow, I totally forgot who I was when I started, why I started, and what I expected from this job. Now I just have a completely pessimistic point of view.” If you’re pessimistic about your job, it translates into how you connect with everything else in your world.

There are situations that get burned in a person’s brain—things that cause flashbacks and nightmares. Those are like my nervous system is stuck on an event in my life that has not been able to be turned off.

It’s as if I’m stuck in Groundhog Day in a situation and an event and a belief system, and those get stuck; my body stays stuck wide open believing I’m still in danger. You often have to take a person back to those events and allow them to have an experience and a new belief system that says, “I actually am safe, my body can calm down and relax, I do have safety and security and the crisis is over; I’ve passed through it.”

PTSD at some level I describe as a stuck state of being in an emergency even when the emergency’s over. Either I’m stuck in the old one or I’m getting ready for a new one, but I can never have a relaxation period in between. If I don’t give my body and mind a chance to relax—just like a car: if I’m running full blast all the time and I don’t stop to get an oil change or fill up gas, I eventually break down—your body or mind cannot run full blast all the time.

Some of those big events you talk about: because there will be some that stand out. Trauma-based therapies are great ideas to help attenuate some of those symptoms. Is there anything else in the last minute or so of conversation you’d like to add?

Everyone Has Trauma, and Trauma Changes You

Craig: Well, PTSD is not reserved only for first responders, and certainly I would give first my admiration for the work they do, but as well the impetus not just for first responders but for everyone. Everyone goes through trauma in life. It doesn’t always mean it has to create dysfunction, but it does change you. If you’re not aware of it and you’re not working toward self-care, it starts to build up and slowly takes you away, and you don’t even recognize that you’re not the person you used to be.

So self-care regarding relationships, self-care regarding emotional health, physical health, even spiritual health. A big part of the world now, I think people are grasping for something to give meaning to life. I think you can’t ignore that. People have to spend some time and say all areas of my life have to be stabilized and have some directionality.

They call the buzzword mindfulness: I literally have to have a sense of direction and purpose for all areas of my life in order that I can steer my life where I want it to go, leading to health and staying connected with everybody else. That’s where the action is. If I have any evidence of my life, maybe I got to ask people around me. A big part of PTSD is you don’t even recognize you’re in trouble; it takes somebody else in your world to speak into your life. If you know somebody in your world that you can see getting in trouble, bring it to their attention because they probably don’t know it.

Be prepared that if somebody brings that to you, you’ll say people are coming to me in love and caring; they don’t want to see me get in trouble. I should be prepared to accept that not as a sign of weakness or that I’m flawed, but that people care about me and that I have the potential to, at some level, have resilience. Part of me says, “I don’t want to return back to normal because I can never, but I can get better, I can be wiser and grow in strength and then use it to help others.”

For Help Processing Trauma, Find a Therapist

Kelly: Yeah, well said. And there’s a lot of good information from what you’ve said today, so I appreciate you coming in and giving us a lot of information around your expertise in working with these noble people that put themselves out there to help people in need. I just wanted to thank you again for coming and speaking about PTSD in particular with people who are first responders—police, firemen, firewomen—and this population. Thank you again for coming in.

For more information, just go back to www.drkellyclark.com, that website there, for more information around transformative therapies. If you yourself suffer with PTSD or other emotional difficulties and you would like to feel better, then just take a look at these resources; we’d be happy to help, because mental health matters in Edmonton. Thank you.

Craig: Thank you.