Trauma treatment challenges (and solutions) by Daniel Mirea

“What happened to you is not your fault, but your future is your responsibility”

For online training in trauma with either Dr Donald Meichenbaum or Daniel Mirea please click on this link

The topic of ‘trauma’ is much more controversial than one would imagine. Research tends to indicate that approximately 25% of people who have experienced a significant trauma go on to develop post-traumatic stress disorder symptoms or PTSD, but that percentage varies. Based on the nature of the trauma those rates are going to be higher, for example for someone who’s experienced rape or sexual assault more like 50% or lower for other kinds of traumatic events like for example a fireman dealing with a fire. An interesting question following on from this data, would be centred around the 25 to 50% people that resume their normal activities, symptoms free after a frightening incident. Such a significantly high percentage might suggest that therapists are presented with an interesting opportunity during treatment, if and when therapy focus is re-directed towards a key aspect of trauma recovery – RESILIENCE. Dr Meichenbaum, one of the CBT pioneers, aka the Freud of CBT, has been talking about this area for decades. Therefore, a justified question would be, how do the up to 75% people deal with their symptoms post-trauma in order to, not develop chronic PTSD? And if resilience is at least one of the answers then what helps improve resilience during treatment?

Whilst there is no agreed definition on what ‘resilience’ means, it is clear that being resilient could describe an individual’s ability to bounce back in face of adversity and according to Dr Meichenbaum it is also relating to an individual’s inner resources and outer immediate support network. His conclusions are backed up by neuroaffective research which describes resilience as the capacity to deal with external challenges, also called ‘exteroception’ or sensitivity to external stimuli, by managing any resulting internal changes, also known as interoception or the perception of internal sensations. Dr Meichenbaum posits that trauma symptoms and resilience engendering behaviours can coexists. The data must not be misinterpreted; it is not that the 75% do not develop some symptoms of PTSD but victims evidence the ability to bounce back and cope with ongoing challenges as such with time symptoms can subside. Moreover, people can be resilient in one area of their lives and not in others. As Bonanno (2022) highlights in his book “The end of trauma”, a key feature of the 75% that are impacted but who engage in resilient engendering behaviours is that they have developed a resilient mindset, a set of optimism and self-efficacy and have ongoing social support (Meichenbaum Roadmap to Resilience).

In cognitive-behavioural terms the implications for treatment are significant; although there is no magic bullet and there seem to be multiple ways to developing resilience, these findings could be translated into high levels of psychological flexibility and adaptability, good problem-solving skills, and an ability to learn and implement new coping strategies which would have to be rehearsed under pressure and in real life experiments.

Trauma characteristics

So, if being resilient is one of the ingredients that could help almost 75% of people exposed to different levels of threat, not to develop symptoms of trauma, how do we identify the remaining 25% ?

When it comes to the label of trauma, much like depression, it seems the over-use of the term itself becomes problematic. The label ‘trauma’ is commonly used to describe a range of situations and experiences that might not fall under that definition.

A traumatic experience may be defined by five main characteristics.  

  1. An experience that is far beyond what may be considered a normal human experience and during which a person feels a significant risk to self or even death; intense fear or helplessness during an attack may also be part of this experience
  2. This experience would extend to witnessing an event where someone is threatened with serious injury or death
  3. This experience is followed by extensive reexperiencing and significant changes to memory
  4. This experience is also followed by increased and frequent states of hyper-arousal
  5. The negative arousal is associated with safety-seeking and other avoidant behaviours

Such experiences are more complex than the stress one would experience during a driving test which might have even resulted in failure and subsequent self-criticism. As upsetting as that can be, it does not amount to a traumatic experience, not unless you had a serious car crash during your test and subsequently kept reexperiencing scenes of the crash, you had become hypervigilant in traffic, and this had also led to avoidance or even social isolation. Waiting for two hours in line at the petrol station during the petrol crisis would not qualify as a traumatic event. Not unless you saw someone get attacked and hurt while waiting in line.

The inconvenience can create distress, but most events we go through daily are not traumatic. One might argue that, to qualify everyday occurrences or even major inconveniences as traumatic is to minimise and trivialise the experience of people who are living with PTSD every day and whose lives were turned upside down by past horrific experiences. It is therefore important to watch over the use of the term because it misses the boat by miles, on how much trauma affects people both psychologically and physiologically.

Another common issue would be convenient access to a lot of online information at a time when unfortunately, not all online resources are legitimate sources of information. The answer is often is a lot simpler. It is wise to try to access a professionally trained clinician or therapist, preferably a trauma specialist. Even though many schools of psychotherapy reject the medical model the evidence stands out. According to Dr Meichenbaum, trust in the therapist, in the therapist’s expertise and in the therapeutic method used, is associated with positive treatment outcomes (link to Therapist Core Skills by Dr Meichenbaum 2022, BABCP competencies – seee BABCP website).

Irrespective of their school of thought, psychotherapists need to familiarise themselves with the psychopathology of trauma, the risks and maintenance factors and feel confident in delivering a variety of therapy methods in response to a traumatic experience or else they are faced with a situation where the blind is leading the blind. In this regard, it seems that choosing the right therapist can be a challenge since a lot of psychotherapists are often led by their personal beliefs or what they might consider healthy scepticism and miss out, on the real symptomatic impact that a traumatic experience can have on an individual (Mirea, 2012). 

Understanding the symptoms of trauma and how these symptoms are being maintained can also facilitate the process of psychoeducation which is yet another important aspect of the trauma treatment. Recovered trauma patients frequently report that if they knew what trauma meant and how it ‘worked’ they would have chosen the right support a lot sooner, they would have had faster results, they would have saved money on treatments and would have resumed their normal lives a lot faster.

Misdiagnosing trauma is surprisingly common for a variety of reasons, not least comorbidity. It seems that 8 out of 10 people with PTSD are more likely to have a comorbidity such as, another anxiety or depressive disorder, or a substance use disorder. Cognitive intrusions and reexperiencing are common across a range of disorders including PTSD, OCD, schizophrenia, or even bipolar disorder, this is where having the skills and the correct training would help therapists peel back all the complex layers of a mental disorder.

An interesting trauma myth is that trauma is only defined by something happening directly to you. You have to be assaulted or raped or something bad has to happen to you. In fact, trauma can also be defined by witnessing something violent like a crime, an assault, a rape or a murder. Common beliefs associated with this type of guilt or shame-based trauma are loud with a strong internal critical or blaming tone: “I’m being ridiculous… I must be weak… I could have done more… How dare I say I have trauma… I am not the real victim here”

Trauma reexperiencing and processing methods

Going through a traumatic experience can lead to a very confused memory data base. At the time when the trauma occurs the individual does not get a chance to fully process the event and therefore a range of problems would rise from there. On an ordinary day, memories are coded and laid down in specific structures of the brain, specifically via the hippocampus, and the neocortical system, best viewed as our long-term memory storage. Here we have access to an event in a narrative format, something one can talk about comfortably, distant stories from our past, which eventually would fade with time.

During a traumatic event this natural process is interrupted by a narrowed and focused attention onto the threatening stimulus, facilitated by high levels of cortisol and adrenaline. The traumatic memory is saved by our internal alarm system called the amygdala, a peanut size brain structure located just anterior to the hippocampus in the medial temporal lobe. The amygdala is a different kind of data storage, in charge with our safety and responsible for keeping us alerted to new similar threats. This is basically part of our fight-flight system, essential to our survival. Because of this, memories about threats or dangers, do not fade with time. Such memories capture all sensory modalities, they feel real, current and relevant. Traumatised victims would find it difficult to share memories of trauma even decades later.

So, traumatic memories are saved in the amygdala ready to be activated at a moment’s notice, if a similar emergency should arise again. With assistance from the Autonomous Nervous System (ANS), all mammals have the ability to re-orient attention toward a potential threat and scan the database in 0.025 seconds. This would lead to an immediate series of reactions designed to preserve life.

Unfortunately, the ANS is far from perfect and impacted on by a variety of unhelpful habits very well-rehearsed by other parts of our brain, such as the tendency to ruminate and worry over unpleasant or scary events. Ruminations and worries in particular seem to confuse our internal processing systems and therefore memories are generalised and constantly updated with more threatening material. As a result, the amygdala would get frequent imprints and the sympathetic response gets easier and easier activated by a variety of sensorial triggers.  For example, a lady who was raped by a bald man, years later, she would feel threatened by all bald men she would come in contact with, irrespective of ethnicity, age or size. At least 25-50% of people exposed to a threat describe flashbacks of the traumatic events as a frightening experience, they feel they are right back there, reliving the traumatic experience. As such, significant efforts would go into suppressing and neutralising flashbacks as well as avoiding places or situations that act as reminders and might trigger the flashbacks.

How to safely integrate traumatic memories

Evidence-based psychological treatments such as the family of CBT therapies rely on a few strong principles such as ACT: Assess, Conceptualise and Treat. We have already understood how important it is to be able to separate trauma symptoms from other unpleasant or stressful experiences that do not come under the same umbrella. Therapy alliance, psychoeducation, new learning, problem solving, installing new coping skills, exposure programmes are all essential and well evidenced approaches across the range of CB therapies.

However, with PTSD cases, traumatic memory processing plays a distinct role. The theory that lies behind memory processing focuses on the influence of the Autonomous Nervous System (ANS) our main survival mechanism which gets activated when we are faced with a threat. The ANS has an ON switch called the sympathetic response which leads to arousal and an OFF switch which is called the parasympathetic response that encourages de-arousal or a calming relaxed response. This sounds great, however one of the problems is that we are not able to consciously switch the system On and Off, as we would more than likely prefer, hence the label ‘autonomous’.

With the risk of over-simplifying a process that is otherwise very complex, it might be easier to understand by separating the hardware from the software components of our brain. It may be important to remind our brain’s hardware which includes structures such as the amygdala, hippocampus, the thalamus and the neocortex. Part of the software include sensorial processing, memories processing and the role of attention-orientation.   The software communicates via different hardware components with the help of neurotransmitters, such as adrenaline and noradrenaline in the case of a threat, via neuropathways or brain circuits that all together create our autonomous nervous system.

The role of the amygdala is to analyse and collect data about threats in order to alert us and keep us safe when necessary. For example, the amygdala would correctly alert us through the emotion of fear, that “snakes are dangerous” if we come across a snake on a mountain trail but in fact, not all snakes are dangerous in all situations and as such memory upgrading becomes relevant in relation to threat recognition and threat identification.

Ironically, for at least 25% of the victims exposed to trauma the system seems to be even less effective and therefore this is the category that requires trauma memory processing and better integration in the longer-term memory systems (hippocampus and neocortex), so that eventually when memories are recalled the threat system will not be unnecessarily activated and instead past events simply turn into stories or narratives from our past.

Updating trauma memories involves going over the traumatic event and identifying specific moments that create the highest level of distress during this detailed recall through imaginal reliving.  Next, identifying positive or hopeful messages, symbols or even other people that add new information and meaning to the event. 

In NeuroAffective-CBT at this stage, attention is also directed towards feelings and physiological reactions by encouraging a focus on the location and the intensity of the distress within the body. This is followed by clear but gentle instructions at every step to keep track of the intensity of the distress and self-regulate through breathing and progressive muscle relaxation, in parallel with the memory recall.

It is important to remember that memory recall in a state of high emotion can increase the arousal to the point of overload sending new sensory impressions in the amygdala. In other words, upgrading the memory with more traumatic material, which might have a negative effect.

            As such, a precursor to this exercise would be a strong bond and a trusting relationship with the therapist, which facilitates down regulation and self-soothing during heighten states of arousal or dissociative states. Grounding techniques, attention training techniques, practising safe place, progressive muscle relaxation and body scanning are proven tools that help with self-regulation.

Safe place or grounding imagery can be introduce at different times in order to establish distance and a sense of safety for example: ‘you are safe now travelling on a train looking at the passing scenery, your memories are just passing scenery…or… you are in your own private cinema, it feels safe, comfortable and distant, you are watching your own memories unfold on the screen, just like a movie, scene, after scene..’.  

All the above present-focused exercises are essential, since trauma recall is reported to dissociatively bring online a sense of being back during the event that caused the trauma in the first place, even if/when this took place decades earlier.  Grounding exercises, safe place, bilateral tapping used in NA-CBT or any other sensorial bilateral stimulation used in EMDR are all meant to downregulate and create a sense of ‘hear-and-now’ by distributing, widening and re-orienting attention during the recall (EMDR article Mirea, 2012).

In TF-CBT reading out the traumatic episodes are also common reliving exercises though the risk for retraumatising is higher without specific memory upgrading. According to Clark and Ehlers (NICE recommends their model for PTSD treatments within NHS) negative appraisals of the trauma poses a special challenge as much of the patient’s evidence for the problematic appraisals stems from what they remember about the trauma. Thus, work on appraisals of the trauma needs to be closely integratedwith work directly on specific traumatic memories. The disjointed intentional recall of the trauma in PTSD makes it difficult to assess the problematic meanings by just talking about the trauma, and has the effect that insights from cognitive restructuring may not be sufficient to produce a large shift in affect and those are a precursor to what is know as re-traumatisation.

Understanding trauma triggers is equally important. The aim would be to break the link between the triggers and the trauma memory. This could be achieved in several ways, including teaching the patient to distinguish between the past – ‘Then’ and ‘Here & Now’; i.e., the patient learns to focus on how the present triggers and their context ‘Here & Now’, are different from the trauma (‘Then’). This can be facilitated by carrying out actions such as movements or bringing to mind positive images or touching objects that grounds and connects the patient within present moment. Patients would practice these strategies in their natural environment during sessions. When reexperiencing occurs, they remind themselves that they are responding to a memory, and this is not the current reality. They could focus their attention on how the present situation is different from the trauma and may carry out actions that would have not been possible during the trauma.

In NeuroAffective-CBT, imaginal reliving is not presented as an intervention aimed at enhancing emotional habituation to a painful memory but instead this is a moment-to-moment detailed reliving, which could and often should be time framed. This helps to identify specific traumatic memories, highly dissociative moments, which would be addressed through cognitive and somatic processing. Bilateral stimulation does not have to be used, not least because tapping is an unusual technique and for some people even inappropriate, as long as attention training, memory upgrading, and cognitive restructuring is carried out in parallel with emotional regulation with the scope of achieving a renewed sense of distance between the traumatic episode and the present moment. Comments such as, ‘I now feel this happened a few weeks (or years ago) and I am no longer in danger… that moment is less clear…’, ought to be the principle aim with this type of processing.

In summary…

Trauma processing is just a small part of the treatment protocol for trauma, a constant focus on therapeutic alliance, problem solving skills and new coping skills ought to be part of the repertoire that enhances individuals’ resilience.  Cognitive and Behavioural therapies have a range of methods and interventions available. For the newly trained CBT therapist, it is important to study as many as possible, and work under CBT supervision with various interventions, constantly developing and refining their ability to tailor the treatment to each individual’s needs, abilities, learning style and personal values.

This article is focused on traumatic memory processing and only briefly outlines other essential interventions. A comprehensive trauma treatment would have to address all mechanisms that predispose, precipitate and perpetuate symptoms of PTSD. This suggests that a series of bio-psycho-social traps would have to be identified and disrupted, According to Dr Meichnebaum positive outcomes are further enhanced by developing resilience rooted in individuals’ culture, personal values and strengths. Meichenbaum has reminded us in his characteristic manner that we are not only homo sapiens but also homo-narrans or story tellers or narrators, therefore the stories that individuals tell will determine if victimised individuals will fall into the 25% or 75% group (Meichenbaum, lecture notes 2022).


Hackmann A, Ehlers A, Speckens A, Clark DM. Characteristics and content of intrusive memories in PTSD and their changes with treatment. J Traumatic Stress. 2004; 17:231–40.(30).

Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M. Cognitive therapy for PTSD: Development and evaluation. Behav Res Therapy. 2005; 43:413–31.(32).

Ehlers A, Steil R. Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach. Behav Cogn Psychotherapy. 1995; 23:217–49

Meichenbaum D (2022). Lecture notes donated by author.

Meichenbaum D (2012). Roadmap to resilience: a guide to military, trauma victims and their families. Available on Kindle Amazon and on the websites: UKCHH and Melissa Institute.

Meichenbaum D (2004). Stress Inoculation Training. Pergamo.

Mirea D (2012). How to stress yourself when you are already stressed.

Mirea D (2012). EMDR, not just another therapy with a funny name.

Bonanno G (2021). The end of trauma: How the new science of resilience is changing how we think about PTSD. Amazon.

What is Cognitive Behavioural Therapy and how does this approach differ from other types of psychotherapy models (audio)

CBT is synonymous with evidence-based psychological treatment. Best understood as an umbrella-term that includes a number of very-well researched therapeutic approaches developed over the last few decades and proven to work with a number of psychopathologies… dynamic talking therapies like Exposure Therapy, Schema Therapy, Stress Inoculation Training, Mindfulness (MBCT), Acceptance and Commitment Therapy (ACT), Hypno-CBT, NeuroAffective-CBT (NA-CBT) and a lot of other acronyms (i.e., MCT, DBT, CFT, FA, etc.) are all part of the CBT family. Although these therapies are designed to operate rather well within the medical model, they remain close to individual values, personal goals and desires…

Daniel Mirea goes into some depth on this topic with accredited psychotherapist Carla Vercruysse on Spotify !

Daniel Mirea about Cognitive Behavioural Therapy

Dr Meichenbaum’s personal story of love, loss and resilience (audio/ video)

Dr Donald Meichenbaum has won many titles and rewards in the field of psychology and cognitive-behavioural therapy but he is less known for his storytelling qualities. If you attended a masterclass in storytelling and writing, you would probably soon learn that gifted storytellers would typically open up with an exciting anecdote or a real story that grabs the audience’s attention, and then they will make sure the last thing they say is something that can resonate with the audience long after the story is over.

Dr Meichenbaum’s personal story has all of these qualities and more. In listening to his story, it is hoped that you will learn something about love, loss, resilience as well as story telling… Because afterall the best gift we can offer the world is our personal stories.


References mentioned in the podcast by Donald Meichenbaum, PhD:

Dr Meichenbaum D, Roadmap to Resilience (free manual)

The Mellisa Institute for Violence Prevention and Treatment

Online training with Dr Meichenbaum

“BOLSTERING Therapists’ Resilience at Work” with Dr Donald Meichenbaum

“BOLSTERING Therapists’ Resilience” with Donald Meichenbaum is part 2 of a series on essential ‘CBT Skills for Building Resilience‘ re-edited and re-published by Daniel Mirea on and with author’s permission for free use and clinical training – the content belongs exclusively to Dr Donald Meichenbaum (this material can also be found on the Melissa Institute and Roadmap to Resilience website)

These are authentic lecture notes and handouts written by Dr Meichenbaum, one of the CBT founders, they were intentionally not edited, so that when you will explore the material you would get a sense of ‘here and now’ as if you are at his lecture right now and he speaks directly to you. Enjoy… but not before you read part 1 of the series which is right here !



  • Create A Formalized Way To Shift As You Leave Work: An Intentional Way Of Leaving Work At Work To Engage In Your Personal Life.
    • Walk
    •  Listen to a specific song
    • Taking a deep breath or two or ten as you leave. Envision breathing in _______ (peace/happiness/serenity etc) and breathing out ______ (stress/anxiety/COVID etc.)
    • Ceremonial changing of shoes/clothes envisioning leaving your work with what you change out of
    • Visualization or conscious thought as you leave: building/parking lot, that you are leaving work at work. Look in your rearview mirror and see it behind you.
    •  Write down the stresses you are leaving and put them in a box/envelop/folder that you literally leave at work to be picked up when you return.
  • Replenish with physical and mental well-being activities and allow yourself to escape
    • Exercise or outdoor activities
    • Create a sleep routine including healthy daytime rhythms: Refer to “Roadmap to Resilience” in Appendix A for How To: Improve Sleep Behavior
    • Outdoor patios/backyards/parks
    • Cherish and foster connections, friendships and family

Reach out to them: virtually through interactive video calls etc. to talk, or do an activity while on the virtual call such as watch the same movie or a walk, electronically with email, text, message or comments on social media, write an actual letter and mail it: a letter to say hi, or a Thank You letter

  • Maintain Healthy Life Balance, Allow Yourself To Recharge
    • Outlets and interests beyond work such as hobbies and social activities
    • Activities that have a concrete outcome to foster a sense of accomplishment:
      • Learn a language, instrument, or new skill
      • Volunteer work, write letters to nursing homes etc
    • Activities that allow you to create and express feelings
      • Garden, paint, dance, writing: poetry or journaling
      • Journaling
      • Writing your feelings to get them out, in a journal
      • Write a letter to someone or about something you’re upset or stressed about. Get all the feelings out in that letter and then destroy it. (tear it in to tiny pieces, burn it, wrinkle it up, and throw it away *Any combo of the three)
  • Recognize You Are Not Alone – Repeat “I Am Not Alone”
    • Consciously pause, think about that phrase. Remember those words when you’re overwhelmed, before work, before you go home – Anytime you forget
    • If you forget. Reach out to a colleague or someone else in healthcare who understands the stresses. You can even create a “disaster plan” to have a sponsor where if you get in a dark place and feel alone, you both know you might reach out to say, I’m feeling alone or have a code word or phrase. To hear them respond with, I feel you/I get it/I’m here – will remind you.

“I recognize that others are going through this as well.”

  • Develop And Cultivate A Philosophical Acceptance Outlook

The Serenity Prayer

“God grant me the serenity to accept the things I cannot change, the courage to change things I can, and the wisdom to know the difference.”

  • Appreciate the positives
    • Commit to find one positive in each day. Create a list/collection of sticky notes, write them in a book. Have a physical copy, that you can look back on and see your progress and also to see there is hope when you can’t think of a positive during a dark moment.
    • Acknowledge and accept things that can and cannot be changed
      • Create a “To Do” list, of things that can be changed
      • Create a “To Let Be” or “To Accept” list – to help you acknowledge things you can and cannot change. Once you acknowledge, you can remind yourself they are things you cannot change. Identifying and reminding yourself, is an actionable step you can take towards acceptance.
    • Work on things you have the ability to change
      • Create a To Do List, of things you can change.
        • For each item in the list, create steps of what you can do.
        • For some of the items, create deadlines. Accomplishing goals gives you a sense of achievement.
    • Take pride in and recognize the privilege in being in a helping profession, especially in the setting of the stress of a pandemic
      • With co-workers, with patients, with family: You are all interacting in a vulnerable space. Look for the magic and privilege. Start a list of things you find in each day. Find one thing in each day. (Invite coworkers to add to the list as well. Have it be visible in a common area.)
    • At work, remind yourself in the moments of interactions with your patients/colleagues/visitors; you are in the helping position that allows you to, during their time of vulnerability, make a difference with simple kindnesses per your interactions of their visit/day.

“The name of the game is IMPROVISE, ADAPT, OVERCOME. Be flexible by necessity.  Take one day at a time!”

  • Spiritual Coping Strategies
    • Active involvement in a religion, online/TV  services, service measures to donate time/clothing/items of need, checking in on or meals for elderly neighbors
    • Each day converse or have a connection with your higher power, out loud on your way to or from work, in the form of a prayer, symbolistic jewelry/emblems as a reminder you are watched over, express gratitude, find purpose
    • “I do Nature Therapy daily. Go for walks- review my nature videos and pictures.  Appreciate the awe of nature.”
    • “I find strength in being altruistic – a higher purpose in life.”
    • “This pandemic is God’s way of testing us. I will meet this challenge and become stronger.”
    • “When I drive home, I am constantly talking to myself and to a higher power. I keep asking questions for which there are no answers.”
    • Refer to “Roadmap to Resilience” in Appendix A for Spiritual Fitness Coping Strategies


  • Assess Your Social Support

“I rely on my “battle-buddy” – my fellow worker who keeps tabs on me and for whom I do the same for him/her. We check on each other frequently at work and at home.”

  • Create an actual list of who would/could be emotional, informational, and or material support? (Might be different people for each type)
    •  Identify: family, friends, coworkers who are helpful. In what ways are they helpful?
    • Create a game plan, whether talking to them or having the list and knowing those are people you feel you could go to in those moments
    • Actively/intentionally maintain connections with peers and colleagues.
      • Set a goal. I will reach out to ____ # peer/colleague/friend each day. Can be verbal if you see them or a form of communication of your choice. Personalize the communication. Instead of just, “how are you?” “How are you doing with the pandemic/pandemic stress?” “How’s your family/cat/dog/kids/job/ holding up during all of this?” “How are you kids doing in school?” “What have you been doing to keep active/healthy/happy/_____?” “Good job on  _____ with that patient/staff/patient family etc. I think the way you (helped them calm down, helped them feel safe, taught them about _____) worked out well”
    • Ask yourself: Do I have the strategies, abilities, confidence and desire to cope with unhealthy, harmful relationships? If not, what can I do to protect myself? How can I learn, or who can I learn from?”

“There is no shame for asking for help. No one can do this alone. I realize I am not the only one with these problems. You do not have to try and do it yourself.”

  • Can you identify a mission, cause, group of family or friends that you can engage with that will give purpose?
    • Can you identify individuals who value joy, improving the situation and who seek productive meaning-making?
      • Community coping efforts or support that generate a sense of hope, trust, solidarity, and connectedness
        • Public rituals, prayer circles, memorials, demonstrations, artistic expressive activities, theatre performances, reconciliation meetings, religious services, live music
    • Can you identify a role model or mentor?
      • What behaviors, actions or attributes do they have that caught your attention as someone to be a role model or mentor?
      • What behaviors do they have that stand out during these stressful times?
        • Can you ask them how they learned the behavior(s) that stands out to you?
      • What behaviors do you have, that are similar to theirs
      • What behaviors do you have, that would be helpful to change so you could develop behaviors similar to theirs?

“I nurture and invest in social relationships. I try to be useful to others. I can text, email, call, Skype, join Internet exercise and yoga classes and chat lines on the Internet, use Zoom, watch Netflix movies with others, schmooze on the phone in order to lift the dreadful cloud of COVID-19 for a little time.  You have to ‘give in order to get’.”


  • Regular Or Semi-Regular Team Meetings As A Form Of “Emotional Check-Up”
    • We don’t need to fix or solve the problems of their stress, but employees need to know we care. The simple act of stating that or phrasing it “We know we can’t fix the fact that we are in a pandemic right now and things have continuously been incredibly stressful. What we can do is create venues/opportunities for you to talk and be heard – on various levels.” * coworkers, managers, EAP have various parts

“People in deep grief (stress/trauma) want to feel that you have heard their pain. If you try to ‘fix it’, you may rob them of that passage. They often want someone they can trust…”.

  • Training/Educational Opportunities To Learn About Resilience, Burnout, Wellness
    • Bring the interventions to staff (especially initially, in crisis/survival mode, they likely don’t have the mindset to begin, to seek out or know what they need or what would help)
      • Arrange for EAP to visit the units/departments
      • Workshops on building resilience to learn which: actions, behaviors and thoughts improve or hinder resilience
      • Create a campaign to initiate awareness for the concern for the resilience of staff

“… support a “mission” and accompanying activities to actively change the circumstances that lead to victimization. This may be done at the local, organizational, and national levels such as advocating for legislative reform and social action. Help workers transform stress into ways of finding “meaning” and “purpose”.

  • Community/Team Building Initiatives
  • Ongoing Supervision, Checking In On Staff

“We have end-of-shift ‘campfires’ – a kind of debriefing where we can give voice to our experiences, vent and problem solve.  We have created a kind of social support group.”

  • Create And Ensure A Psychologically Healthy Workplace In A Way That Is Actionable And Visible And Ongoing
    • Psychological health includes the need people have for feeling connectedness and sensing belonging

And finally the difficult part… how much time do you spend evaluating your work and if so how do you do it, are you being too critical, or avoidant, or scared to find out what your patient really feels about the therapeutic process and about you… what are the questions that you need to ask in order to improve your approach?


On a Scale from 1 to 5, where 5 indicates that you are very SKILLFUL at doing the therapeutic’ activity (even can teach it to others), and where 1 indicates that you still consider yourself a NOVICE, Rate yourself. A Rating of 3 indicates that this therapeutic activity is still a BUDDING SKILL.

___  1. AGENDA SETTING — At the beginning of each session. you and your patient together can establish an agenda to discuss and explore specific issues and patient concerns.   

 ___ 2. PATIENT FEEDBACK — On a session-by-session basis you routinely elicit both your patient’s positive and negative reactions to all aspects of the therapy session. You may use some form of Rating Scale and discuss the patient’s choices and reactions, or you can use the Art of Questioning to elicit   such patient feedback.

___ 3. COLLABORATE WITH THE PATIENT — You are able to establish a collaborative relationship with your patient when establishing Treatment Goals, when selecting “Homework” activities (Commitments to undertake personal     experiments). You can include a Treatment Rationale that increases the            likelihood that your patient will be actively engaged in the therapeutic              enterprise.

___ 4 USE GUIDED DISCOVERY AND THE ART OF SOCRATIC QUESTIONING — Help patients better appreciate the interconnections between their feelings’     thoughts and behaviors. (USE THE CLOCK METAPHOR). Help patients           better appreciate how they inadvertently, unwittingly, and perhaps,                   even unknowingly, emit behaviors that trigger reactions from others                 that reinforce their views of themselves, others and the future.

(Remember “There is no situation so bad, that by your own efforts you can make it worse.”)

___  5. USE ACCURATE EMPAHTY — You can communicate an understanding of your patient’s feelings and thoughts and address any ambivalence the patients have about changing their behaviors. Convey that you are trying to see the world through their eyes. Validate, normalize, and even help reframe your      patients’ reactions.

___  6.  ELICIT YOUR PATIENTS’ STRENGTHS— Help patients access and appreciate the resilience and Islands of competence that they bring to therapy with them, Ask HOW and WHAT questions concerning these “In spite of behaviors”. Help patients develop a RESILIENT MINDSET.        

___  7. CHALLENGE YOUR PATIENTS TO UNDERTAKE PERSONAL EXPERIMENTS — Encourage your patients to engage in between session activities in order to test their hypotheses and expectations. Help them achieve a “new positive ending ” to an old issue or conflict.”  Ensure that your patients take these results / data as evidence to unfreeze their beliefs.

___ 8 . USE CHANGE TALK, THE LANGUAGE OF POSSIBILITIES AND BECOMING — Ensure that your patients take credit for any behavioral changes. Ask patients for examples as for how they were able to (USE RE Verbs RE-connect, RE-prioritize, RE-author etc.) engage in Meta-cognitive personal agency activities (“Notice. plan, choose etc”). Not allow their emotions to HIJACK their Frontal Lobe Executive TYPE 2 thinking processes.

___ 9. PACE THE SESSION APPROPRIATELY — You use the therapy time effectively, combining the patients’ concerns and desire to connect with you and the eeded focus on ways to achieve the agreed upon treatment goals, Continually explore how what is being addressed in therapy can be applied by the patients in their everyday experiences?

___ 10.  STRATEGICALLY AND SKILLFULLY EMPLOY THERAPEUTIC            INTERVENTIONS — Select from an array of Cognitive behavioral and Constructive Narrative interventions those treatments that best meet the clinical needs and patient preferences. Meet the patients where they are at. Build in generalization guidelines, no matter what treatment approach you adopt.