Welcome everyone to Looking to the East. I'm your host, this temporary host today for the show. My name is Steve Zercher. I'm a professor at Kansai Gaida University here in Osaka, Japan. Welcome. We'll be discussing an interesting topic today related to Japanese immigration and Japanese demographics. So this is a topic that Jay Fidel, who is with me on this show, suggested that I investigate and this is turned into the show today. So thank you Jay for making that suggestion to me. Before we switch roles here, Jay is going to become the host. Just want to briefly update everyone on some news items coming in on Japan. First of all, Jay, I'm sure you'll be very happy to find out that Roma Manual is now in the country. We have the rominator in Japan and he is officially serving as ambassador of the country. So very excited about that. We have no idea how that's going to turn out, whether his old habits will conflict with Japanese polite culture or maybe he'll do an excellent job. We'll have to see. Second, in terms of what's going on for COVID, Japan is experiencing now what Hawaii went through, I guess, a few weeks ago. We're hitting peak numbers in terms of infections. A few days ago, the total was 50,000, which was double the highest ever during the Tokyo Olympics. We've hit 25,000. As a result today, the Osaka government, where I live, is going to announce a quasi-state of emergency. So I'm not quite sure what that means, but it'll be announced today. Probably drinking will be curtailed after eight o'clock and maybe people will be encouraged to work from home. Now, that kind of leads into the next item.  That was started in November after just a two or three week of period of openness. Jay, there are currently 400,000 people that are waiting to get into this country right now. The majority of those are students. This is causing a lot of concern within the economic community here in Japan because a lot of these people are temporary workers, which we'll talk about as we get into the show. It's quite remarkable. Japan is the most severe when it comes to immigration policy and COVID. It's been two years now that we haven't had any international students on our campus. We had over 400 students applied to come this semester and 400 returned away, unfortunately. The last thing is that we do have a new prime minister who met with Biden over the Zoom or over the telephone just recently. There's now been a connection between President Biden and new Prime Minister Kishida. The interesting thing about Kishida is that he, of all the prime ministers in recent history, has a more maybe liberal perspective. The party he comes from is quite conservative, but he's pushing very strongly for wage increases. So, he's expecting Japanese companies to increase wages across the board up to 3%. The income level in Japan has been flat to trending down for almost 30 years now. Excuse me. So, he's attempting to try and defeat that, reinvigorate the economy by encouraging, not forcing, but by encouraging Japanese companies to pay their employees a higher salary than what they had been historically, which has been averaging around 1% at best. Okay, so that's an update on what's going on in Japan. So, at this point, Jay, I'll turn it over to you and we can talk about this immigration dilemma. And I'll become the guest. I'll magically reappear here as a guest for this. So, this reminds me of the old days when I started this show. You were the host and I was the guest and we talk about Japan. So, thank you very much for doing this. Well, thank you, Steve. I've waited for the invitation ever since we started talking about that article in the newspaper. Yes. You know, back a few years ago, we talked about the world getting flat. We talked about globalization. In fact, that was one of ThinkText's, you know, main areas of inquiry, how the world was getting flat, how the borders were coming down, how we were on the way to a world that was completely polyglot in the not-too-distant future. But you know what? That has ended and part of it has ended because of COVID. COVID has changed that, not only for the duration of COVID, but beyond COVID. And Japan never really got on board because Japan has a cultural thing, as you said before the show. Japan is for the Japanese. And so, we saw that. We see it now and we can predict it will be that way in the future. So, can you talk about how that expresses itself? And also, can you talk about why? Yeah, that's a fascinating question that the foreigners like myself who are long-term residents here try and wrap our mind around. I remember reading a book by a foreigner who was part of a missionary family. She was born in Hokkaido and lived her entire life in this country, was fluent in Japanese. And she was talking about her many experiences in Japan. And she concluded, I've lived here my entire life, but I will never be Japanese. It's just not possible even for someone who's born and raised and lived their entire life in this country. I think that's a result of the fact that Japan's a homogeneous society. 98% of the people who are living in Japan about that number are Japanese. There's a myth about the history of Japan, its ancient roots, which go back to religious beliefs that the Japanese people are special people with this long history and this long culture. So I think that's maybe the primary driver why Japanese people think of themselves in this unique sense and that this country is belonging to Japanese. Now, I have to say on the counterbalance that I've lived in Japan a long, long time. I came here as a student. I've been here as a professional working for Hula Packard and other companies. Now I'm a professor and a dean. I have two children and in their lives and in my life, I've never experienced any resistance or any kind of overt racism when it comes to me being non-Japanese. That's been my own personal experience, although there are others that I do know whose children in school systems have been bullied because they're either hafu, which is like hapa. We have the term like that in Japan, or they are just outsiders and treated in that way. So I think it's an outcome of the beliefs that the Japanese people have about themselves, which tie into their history and their religion. And also just pure demographics, Jay. It's 98% of the Japanese. It's for Americans, especially Hawaiians. It's hard to imagine that there's just one group that dominates the culture and dominates the demographics in that way. Hawaii, everybody's in Hawaii. It's just one of the attractions for Hawaii. It's interesting because I think there were a lot of countries that were candidate for the same kind of cultural purity, not to use that word, but in Europe. But then the migrants came from the Middle East and Africa and changed that all around. And now those countries are polyglot, including countries where it creates a certain amount of contention. It does create a certain amount of contention to open your borders. I'll never forget my wife and I were traveling in Europe one time and we were going from France to Germany, or was it Germany to France? And we wanted to see the border, but there was no border. In the EU, you just drive down the road. There wasn't a line on the road. There wasn't a sentry. There wasn't a fence. Nothing. You couldn't tell at all that that was the border between the two countries. And I realized that the EU had created this kind of polyglot and much more the case since the migrant issue began from the Middle East. And Angela Merkel, whose policy it was to let everyone in, and she was a Nobel Prime Minister for that reason. Anyway, Japan hasn't gone that direction. And Japan stays the way it is. And I think one thing about Japan is that, yes, it would appear, the answer to my question is that's not going to change, but there must be somebody in Japan who thinks about this and who says, wait a minute, A, we're not keeping up with other places and B, we're supposed to be an industrialized nation, but we're running out of human resources because the bell curve is upside down in Japan. The birth rate is really, really low for a lot of reasons. We should talk about that. Right. And if you don't allow immigration on top of that, what happens is everybody ages out so that if you were looking for human resources, they're not there. Right. Yeah, you've nailed it. That's a description of what's going on in this country. And there are forces that are continuing to limit immigration into the country, despite the demographic cliff that Japan is falling off of now. So just to illustrate that, as of today, the population of those in Japan that are 65 is 30%. So basically, Jay, in this country, one in three, almost one in three people are over the age of 65. To give some color to that, I looked up Florida, which is the state that has a reputation for where all the retirees go and so forth. There, it's 20%. 20% are at 65. So Japan is 50% higher than even Florida. Another statistic that just is really surprising is the number of people who are over the age of 100 in this country. Jay, what would you hazard a guess? The number of people who are over the age of 100 in Japan? Well, I think what you're getting at is a lot of people are, but let me guess at 5% to 10%. Okay, I don't know the percentage. I was thinking of the raw numbers, and the raw numbers are 86,400. 86,400 people in this country are over the age of 100, which is remarkable. Japan is the world. It's going that way in other places too, but in Japan, you have a serious longevity capability. This is always the case, yeah? It's a very healthy society. Japanese people tend to eat less food than Americans do, and also in general, although this is changing, the balance of the food is healthier, more vegetables, less protein, and so forth. So that's a part of what's going on. Also, Japan's medical system is one of the best in the world. So it's taking care of these people as they grow older. The number of people who are exiting from the workforce every year is 500,000. Every year, the number of workers in Japan is going down by half a million. The population overall, right now it's 125 million. So in 2050, so about 30 years from now, it will be 100 million. And beyond that, in 2065, the population according to demographic forecasts will be 88 million. This country is shrinking dramatically, and the replacement birth rate is around 1.4 or so, so well below sustainability. Families need to have at least two children, actually a little bit more, to keep the population stable. Those numbers are so far in the past, those are decades ago. Anything under something like 1.8 or 1.9 is not sustainable. That's right. So that's what's driving it. Now, everybody knows this. Japan's known this for 20 years. You know, political scientists and demographic experts are saying, this is the direction the country is going in. And now the rubber's hitting the road, because the population is beginning to decline after it had been predicted for many, many years. And that brings us back to the immigration issue. So you mentioned European countries. I would imagine Merkel opened up her borders, because she recognized she didn't have enough German people to fill the jobs that were required, right? She couldn't have a sustainable economy. That might have been a factor. But for her, taking a look at her as an individual, it was on a moral plane. Unfortunately, not everybody in the country agreed with her, and that was a weakness. But she was doing it because she wanted to clean up Germany's issue from the war. Okay. Well, here the push for immigration comes from the business community. If you go to Tokyo and you go into a 7-Eleven, there are no Japanese people working there anymore. The 7-Eleven cannot hire Japanese people into those roles. You find people from Sri Lanka or Malaysia or Thailand or Vietnam. So these companies recognize that in order to run their business, they need to get labor. And the labor in Japan is just not sufficient, especially in the service industry. So Prime Minister Abe, a few years ago, created what was called a backdoor immigration program. Basically, it's special work licenses, allowing people from other parts of Asia to come in. And the numbers that were forecasted were 3,000 to 400,000 to come in to try and backfill this labor shortage that the industry, Japanese business, obviously, is very strong politically in Japan. And the Jiminto, which is the dominant party that Abe belongs to, is very responsive to the business requests. So despite this issue that we talked about at the top of the show, Japan belonging to Japanese only, and many right-wing political people are very vehemently anti-immigrant, especially Koreans. But because the business community was so desperate for labor, he began this backdoor program. But the numbers, even if they had fulfilled it, were still quite small and wouldn't even approach the gap between the jobs required and the number of people available. But then COVID hit, Jay, and all of this stopped. It completely stopped. So the country now is really suffering. As I mentioned, there's 400,000 people that are waiting to get into this country, and many of them are temporary workers on a five-year work plan, and they can't get in because the Japanese government is saying, because of COVID, nobody can come in. So it's a very, very difficult situation. What about the larger political vision of this? Is the prime minister interested, the new one you mentioned? Is he interested in trying to solve this problem? Because this is a life-and-death problem for the economy and thus the country. You're talking specifically about the immigration issue? Well, you have a low birth rate, which is a cultural thing. We hope we have a little time to discuss that. You have this thing about we're not going to allow immigration. You have this thing about aging out, and at the end of the day, you don't have enough people to staff the 7-Elevens or many of the elements of the industrial community. So somebody should be saying, hey, we've got to solve this problem. We've got to be smart and thoughtful and come up with a solution. Is there a political initiative there? This is like the third rail in Japan because of the sense that Japan belongs to the Japanese. So Abe, when he put together this Back to Immigration program, he didn't call it immigration. He can't use that word. That's no go. It was a guest worker program, temporary guest worker program. So it was able to slide through without the pushback from those political segments of the population and the political or among the Gemento, the LDP party that would be against immigration of any sort. So it is being discussed, but it's very, very politicized because the general perception is that immigration is not a good thing. It's not actually, it's not rational to take that position. Well, they'll mention countries in Europe, maybe some of the ones that you're talking about and the disruptions that are occurring there, Germany in particular is called out as an example. Jay, even in our own country, the past president was anti-immigrant. So some of these issues become politicized in various countries across the world. In Japan, it's not overt, but it's definitely there. Steve, I want to ask you some questions that came in while we were talking. This goes back to the beginning of our discussion. What is the Japanese opinion of Rahm Emanuel? Is he getting the welcome matter? Why? I think so far, so good. They recognize that he has a very colorful political history, but the thing for the Japanese, the most important thing is that the ambassador has the ear of the president and it's clear that Emanuel does have a good relationship with Biden. He was the chief of staff under Obama when Biden was vice president there. So I think overall they're happy. It's been a two-and-a-half year gap. We haven't had an ambassador here. Hagerty left the previous ambassador two-and-a-half years ago to run for Senate in Tennessee, which was successful. So they're happy to have him in place. There is a little bit, among my colleagues when we talk about this, we're not quite sure if Rahm's tendency to speak off the top of his head will get himself into trouble in Japan, because Japan is a very measured society and comments are scrutinized very carefully. But I think overall people are happy to have an ambassador back. Yeah, it's a strange thing where we cannot have a robust foreign policy, foreign relations with a country if we don't appoint the ambassador. The same thing happened in Ukraine for years. No ambassador. I don't understand that. You think that out of 330 million people, we couldn't find anybody? It's challenging. Okay, there's some questions about Hawaii here too. The Japanese love to come to Hawaii. Are they seeking diversity? Do they enjoy seeing the diversity of Hawaii? Because that's one of our big sales points indeed for the world. Then related questions, what explains the close friendship between Hawaii and Japan? It goes back to King Kalakaua, when he met the Meiji Emperor years ago in the 19th century. We have had a connection. And of course, we had a connection in populating the sugar companies with labor, back in the late 19th century and the early 20th century. So we have been in touch with Japan for a long time. And they seem to like us. Go ahead. Without question, Jay. Japanese people love Hawaii. But who doesn't love Hawaii? We all love Hawaii. It's such a beautiful place and the Hawaiian people are so special. I've certainly experienced that. I love Hawaii. In terms of diversity, if the Japanese go to Waikiki, it's not very diverse there. It's mostly the Japanese community. But my students talk about that. When they go abroad, they are blown away by the diversity of the United States in general. They are very happy to see that. And they often come back and say Japan should be more diverse itself. In terms of the relationship between Japan and Hawaii, I fully agree with you, Jay. Because of the Japanese community being so strong, in a way, if we go back to the earlier days and the influence that they had on the development of the country, the linkage between the two places between Japan and Hawaii is very, very strong. Abe has gone to Hawaii when he was prime minister and many Hawaii officials come to Japan on visits and so forth. And I think tourism is the basic tenet of the economy that binds us. Hopefully that will return. I'm sure once Japanese can travel again internationally, they can't right now. They'll be back in Hawaii in significant numbers. Yeah. Well, and when they come back to Hawaii, let's look at what might happen. If we were able to solve COVID, I'm not saying we will or can, but what would happen? Let's assume that the travel restrictions are off. And that means not only Japanese coming to the US and coming to Hawaii, but also coming from other places to Japan as tourists. What are the places that like to send tourists to Japan? And what are the tourists that Japan likes to have from where? What's their main connection? Okay, you're talking about tourists coming into Japan? Both ways. I think in terms of Japanese people going to Hawaii, I don't talk to anybody that anywhere who's not excited about going to Hawaii. If they haven't gone, they want to go. If they've gone before, they want to go again. There's a very strong positive relationship between Japan and Hawaii. I certainly advocate for the state all the time. I'm in front of my door, my office, as a Live Hawaii, a Loha sticker that I got from somebody. So I'm promoting the state myself in my own small way. And in terms of inbound tourism, as you know, I have a hospitality program. So I talk to the general managers. And through COVID, they are trying to focus more on high-end tourism. So they would welcome people from Hawaii because they're coming from a developed country. They're trying to get people who will stay at the nicer hotels and spend more money. Historically, before COVID, the bulk of tourists were coming from China. It used to be high-end Chinese would come in, but then the demographics changed so that more middle-class or lower middle-class Chinese were coming in. And there was a pretty strong negative reaction about that. Not so much because they were Chinese, but just the way they spent, the way they behaved and so forth. So right now, if Japan could have its way, it would try and have high-end tourists come in. People who are more well-off, who have traveled before, that's what Japan's... And who are respectful of their... That's an element as well. What about Japan, Japanese people from the U.S., including Hawaii? Do they have an advantage in traveling to Japan? Are they well-liked? Are they accepted? Are they treated a little better? Yeah, I think if there's still family connections, if the auntie or the grandmother are still living in Japan, I think, yeah, that's a very positive reason for travel to the country. Right? If you put the context slightly different, if you look at Nisei or Sansei when they come into the university environment, there is an expectation by Japanese that if you are Japanese, even if you've been in America, maybe your second generation, you should still speak Japanese and you should still be knowledgeable about Japanese culture. So sometimes Nisei and Sansei, they come on a longer-term basis, feel a little bit oppressed because there's an expectation that they should be familiar with Japanese language and Japanese culture and they're not because everyone goes through that Americanization. When I went to Italy, I'm Italian background, my Italian family said, why don't you speak Italian? So even my mother didn't speak Italian, we just give up the language, we all switch to English primarily after a certain number of generations. So I think overall on a travel, a tourism basis, I think most Nisei and Sansei are very happy to be in Japan. Jay, everybody who comes to Japan loves this country because it's like Hawaii in a way. Japanese people are so nice, they're so supportive, this is so safe, and this country also is very, very beautiful. So there's a great experience, which is why Japan was just skyrocketing in terms of tourism before COVID and it will come back. But then for those to stay longer, because the expectations are you're Japanese, you should speak Japanese and maybe you don't. There's a little bit of a sense of unease there. For me, they look at me, they go, no way, he doesn't speak Japanese. So the expectations for me are lower. So I have, when I do speak Japanese, I just, oh, it's amazing. The European Caucasian guy can speak Japanese, they're surprised. But if I was Nisei or Sansei, they go, yeah, he's Japanese, he should speak Japanese. Well, if you wanted to apply, you had something before I go to that. Yeah, I just wanted to very briefly get to the point about what's behind the demographics. Why is this the birth rate going down? And of course, that's a very complicated question, but a lot of it has to do with the role of women in the society. The economy, as I mentioned at the top of the show, has been going sideways for many, many years. So women have begun to get more involved with work. And the dynamic between husband and wife, it used to be the husband was the provider and the woman stayed at home. That's been thrown out the window now 70% of Japanese are working. But that, but in the household, men are still not contributing at all to household chores or raising the family. There's still the traditional model that many Japanese men work under even though their wives are working and the wives are under pressure. So the wives are doing everything at home that they used to and then they're working as well. So it creates a dynamic where women really are exhausted and the birth rates are going down. Also, many women are not getting married. They're choosing not to. For example, the number of unmarried women between 35 and 39 about 15 years ago was 10%. It's now 25%. So you can see that women are choosing to avoid that dual life of working in the home, taking care of everything, taking care of the in-laws and also working outside. So women are under considerable pressure. And that's one of the factors behind the drop off of the demographic. It's a lifestyle thing. I would enjoy the good life. Yeah. They'll look at that and go, Hey, I can work. I can buy my own apartment. I have my friends. I can go out. That's a more fulfilling life than marrying into a family. I mean, this is generally right. There are families where the dynamic is different. Certainly my family, the dynamic is different. I do more household work than my wife does actually. That may be one of the reasons she married me, Jay. I'm not quite sure. So I don't want to say that's true for everybody, but that's true generally. So if you or some other Holly person like me wanted to apply for citizenship in Japan, what would that be like? It's possible to do. I'm now a permanent resident. So I have the equivalent to a green card. That's because I'm married to a Japanese national. So I think how long ago, maybe seven or eight years ago, I applied for that and was automatically granted it. So if I wanted to become a citizen now, I could apply for it and get it very easily. I have a long work history in Japan. I have children here. I fit the profile of a responsible person. If I did that, Jay, of course, I'd have to give up my American citizenship. So of my friends in the expat community, there's very few people who would actually consider doing that or who have done that, but it is possible. I could become a Japanese citizen, thus allowing me to vote in the elections and so forth. But again, like we were talking at the top of the show, I would never be accepted as a Japanese, even if I was a Japanese citizen. That just would never happen. It's a problem. I mean, I don't think if I were the Prime Minister, I'd advocate for an open door policy, but I might advocate for some kind of softening, some kind of temporary or limited opening to have enough trained people come to replace the human resources that are being lost by these other processes, by the low birth rate, by the aging out, by any number of things. And so my last question to you is the Charles Dickens question. What about the ghost of Christmas future here? If this keeps going, if COVID maintains a threat, if these bell curve phenomena keep on limiting population growth, if the political and cultural climate keeps on discouraging immigration as a political cultural matter and the population goes down and they cannot fill the jobs and the schools, what happens to Japan? Economically, it just sinks. So the other day, I saw that Taiwan and Korea in a couple of years will have a higher per capita GDP per capita income than Japan. And I've seen forecasts that Japan will drop down on the top economies from number three, or it's currently to number five, to number seven, to number nine. It's just inevitable. There won't be enough people to sustain the economy. The taxes will become incredibly high here because the younger people who are small in number will be paying taxes to support the older people who are becoming huge. Like I mentioned, 30% are over the age of 65 and they're consuming most of hospital services and government services. I'm always short-term optimistic about this country because the Japanese people are so resilient and brilliant. Japan was devastated after World War II and in less than 20 years it became the second economy in the world, just remarkable. And look at what happened with the nuclear power plant and they recovered from that. And the seismic events and the weather events and climate change, they recover every time in a matter of weeks. They're back to business. That's remarkable how resilient and talented the people are here in Japan. So I remain optimistic, but given these demographic factors, given this inclination of Japan to not be able to manage immigration in a mature way, there's still this kind of emotional reaction to immigration. Long term, it's not good. So the ghost of Christmas future when it comes to Japan, it's going to be tough. And that has a secondary effect, of course, in terms of the balancing of economic and geopolitical power in Asia vis-à-vis China. That's a topic for another show. What's going on between the United States, Japan, and China right now is remarkably interesting. It's hard to predict how that's all going to roll out. But you're right. If Japan loses economic power, its influence in the region goes down. China dominates to even greater extent in Asia. Yeah, looks like I have to get along in my Samsung television and not have any great expectations about Sony. Never mind. Steve Zercher, the host of this show. Let me offer you the opportunity to close now. Well, I want to thank you, Jay. I always enjoy your questions. You are so good at what you do. Thank you for suggesting this topic. And I ask the viewers of this to tune in two weeks. I'll have looking to the East Show again, another topical subject regarding either Japan or Asia. So, again, thanks, Jay. Appreciate switching roles for this show and makes me nostalgic for the early days when we started the show a couple of years ago. Thank you so much. Thank you, Steve. And congratulations yet again on winning the award for the best of our shows. Oh, I appreciate that. Thank you, Jay, for your support of my humble show.


1. Treats of the place where Oliver Twist was born and other circumstances attending his birth. Among other public buildings in a certain town, which for many reasons it would be prudent to refrain from mentioning, and to which I will assign no fictitious name, there was one anciently common to most towns, great or small, to it a workhouse. And in this workhouse was born, on a day and date which I need not trouble myself to repeat, in as much as it can be of no possible consequence to the reader at this stage of the business at all events, the item of mortality whose name is prefix to the head of this chapter. For a long time after it was ushered into this world of sorrow and trouble by the Paris surgeon, it remained a matter of considerable doubt whether the child would survive to bear any name at all, in which case it is somewhat more than probable that these memoirs would never have appeared, or if they had, that being comprised within a couple of pages, they would have possessed the inestimable merit of being the most concise and faithful specimen of biography extant in the literature of any age or country. Although I am not disposed to maintain that the being born in a workhouse is in itself the most fortunate and enviable circumstance that can possibly befall a human being, I do mean to say that in this particular instance it was the best thing for Oliver Twist that could by possibility have occurred. The fact is that there was considerable difficulty in inducing Oliver to take upon himself the office of respiration, a troublesome practice, but one which custom has rendered necessary to our easy existence, and for some time he lay gasping on a little flock mattress rather unequally poised between this world and the next, with the balance being decidedly in favour of the latter. Now if during this brief period Oliver had been surrounded by careful grandmothers, anxious aunts, experienced nurses, and doctors of profound wisdom, he would most inevitably and indubitably have been killed in no time. There being nobody by however but a pauper old woman who was rendered rather misty by an unwonted allowance of bear, and a Paris surgeon who did such matters by contract, Oliver and nature fought out the point between them. The result was that after a few struggles Oliver breathed, sneezed and proceeded to advertise to the inmates of the workhouse, the fact of a new burden having been imposed upon the parish, by setting up as loud a cry as could reasonably have been expected from a ma-


Hi everybody and thank you for coming today. We are going to be discussing a strengths-based biopsychosocial approach to working with people with PTSD over the next 45 minutes or so. We're going to highlight the functional nature of most behaviors and reactions. One of the things that I found when working with patients with PTSD as well as, you know, just about any other diagnosis is the fact that they look at it as a pathology. They look at it as something that's broken when in reality, if you take a different approach to it, you can see how it may not be the best way of dealing with a situation, but it is a survival mechanism. So then we'll define PTSD, examine the function and meaning of PTSD symptoms, develop an understanding of why some people develop PTSD and others don't, and explore useful interventions for working with persons with PTSD. So it's important to remember that humans and animals experience reactions that prompt behavior. So when something happens and we perceive a threat, then our body sends out all those get-up-and-go chemicals and it tells us that we need to either fight or flee.  It's saying there is danger for some reason and this danger can be real or it can be overgeneralized like maybe you're sitting in the living room and a cabinet bangs in the kitchen and you startle. Well, that startle response is natural.  People with PTSD tend to be somewhat hypervigilant and the startle reaction may be overgeneralized. They may be more stressed out and more reactive to certain situations.  It says there's a threat and then how we deal with it is really what we want to work on with most of our patients. The other reactions that we get are designed to help people avoid punishment or achieve a reward. So this is not so much with PTSD. This is more with anything else that prompts a behavior. But it's important to remember that basically we have two reasons for doing something, protection and reward. PTSD, and this is one of my favorite topics, if you will, or pet topics, I focused my dissertation on it. Because PTSD normally we think about something that occurs to someone when they have a single or maybe a couple exposures to really traumatic events. But there's something called gradual onset PTSD, which is common among military personnel, law enforcement, and even sometimes emergency room doctors and people like that who are exposed to trauma and horror on a regular basis. I mean, things the rest of us probably wouldn't even dream of seeing.  There's also a gradual onset PTSD that has been associated with child neglect. Because if you think about it, a child who is two, three, four years old, if mom and dad aren't there, they disappear for days on end, that is perceived as a big threat because a two, three, four-year-old can't feed themselves. They can't take care of themselves. If mommy and daddy are fighting all the time and, you know, the people that are supposed to take care of them, there's a threat that they may disappear, that's very traumatic to a small child. So they've seen that some of the brain changes that we associate with post-traumatic stress happen among children who grow up in households where there's a lot of violence, where there's a lot of neglect. Traditional exposure to an event or multiple events can be like military if you're in combat and you kill somebody. I mean, that is a very defined event. Crime victims, people who are victims of rape, people who are victims of domestic violence. Gradual onset, we want to look at things like law enforcement. Can they be faced with a threat to their life? Can somebody point a gun at them? Sure. More often than not, though, with law enforcement officers, it's seeing amazingly horrific events day after day after day that eventually starts kind of changing their perception of the world. Military, not all military personnel are actual frontline combat type people. Maybe deployed, though. Think back to, I'm going to date myself here, the show MASH. Being in a medical unit that is kind of behind the front lines but still right up there and in harm's way produces a sense of threat. It's not a safe environment to be in. My uncle, you know, to this very day, you don't want to wake him up from a deep sleep because he wakes up swinging and that is kind of a throwback to his days in Vietnam. He wasn't ever in the front lines, but he was always hypervigilant when he slept. He didn't ever sleep well. Still doesn't. And child abuse and neglect, we already talked about. So I want you to kind of broaden your thoughts about what post-traumatic stress looks like and understand that it deals with people experiencing a sense of helplessness and that they can't really integrate with the way they see the world. It's out of context or it conflicts with some of their truly held beliefs. The definition is an exposure to a horrifying event in which there was a sense of helplessness and potentially a threat of loss of life. So each symptom that we're going to talk about, I want you to think about the function of the symptom. Why will the body do that? What is the function of it? How does it help the person survive? Or how does it help the person exist? What triggers that symptom or exacerbates it? So think about if you have a client with PTSD or just hypothetically you had a client who had PTSD and they had the symptom, what do you think would make it worse? Likewise, what could make it better? What might help them? And we're obviously going to ask them this in a strengths-based approach. We're going to say, you know, these flashbacks you're telling me about. What kind of things trigger your flashbacks and how can you prevent them? You know, sometimes you may feel like your flashbacks are a lot worse and you're having a lot more of them. What happens that sets that up where they're worse or more frequent? And when you do have a flashback, how do you deal with it in order to kind of keep control of what's going on? And then we want to hypothesize or theorize about other things a person could do in the midst of these symptoms because they may not have a real good grasp on what to do when some of these things happen. And I'll share with some of my experiences as we go through so you can kind of connect it with your clients. Re-experiencing the traumatic event through intrusive or upsetting memories of the event. Flashbacks, nightmares, feelings of intense distress when reminded, and intense physical panic reactions to the reminders of the event. Okay, so let's talk about memories. These can happen asleep or awake. So what is it that might bring about these memories? Are there smells? Are there sites? Are there situations? I've mentioned before that my stepfather lost his first family in a fire way back in the 60s. And you know, so Christmas time tends to exacerbate his upsetting memories. And yes, it's been a long time and he's learned to deal with them. But Christmas time, Christmas lights, seeing fires, especially house fires are extremely triggering for him. Other things, I worked with a law enforcement officer who had responded to a accident on the interstate and the truck driver was pinned in the semi. And the officer, you know, got up on the side and was trying to get this guy out. And eventually, long story short, the officer had to step down because the semi was fixed and to explode. And he watched this guy burn alive. So that being said, being on the interstate, being around semis, smelling gasoline, smelling smoke, there were certain smells that could trigger it. Helping him understand what the re-experiencing, what triggered the re-experiencing. So the next thing is to say, why? What's the purpose of re-experiencing this event? Well, for one, and you know, if you think back to Piaget, you can think about assimilation and accommodation. Whatever happened didn't fit with your worldview.  Or, you know, that you would ever come home and this would be part of your life. So having to figure out how to integrate that is one reason why it may come up because it's not, you haven't made sense of it yet. The other reason we might look at it is to say that this situation did produce a huge sense of helplessness.  So if you smell this, this smell, it tells you that there's a potential for danger. And we don't want to go towards danger. We want to go away from danger. So you need to get out. So it's kind of a constant reminder of you need to protect yourself. Working with clients and cognitive processing therapy is very helpful with this, among other things. But helping clients be mindful of what is going on with them, helping them stay anchored in the present, and helping them make sense of what happened. And this is what we can do in counseling. This is kind of where our function kicks in. And how that situation, whatever it was, is different from now. Because that situation was awful. And I'm not going to take that away from them. I'm going to let them process that however they need to. And we're going to talk about that a little bit later. But I do want them to look at right now. The reaction that they're having, is it logical? You know, if they're on the interstate, and they're stuck behind a semi, and it's a traffic jam, and they start smelling exhaust fumes, is it a rational reaction to get in a panicky state? It takes time for people to learn to kind of counter condition some of these automatic thoughts. But helping them become aware. Nightmares is another huge one for a lot of people with PTSD. And when I ran a clinic, or a program in one of my clinics for veterans, they would often wake up in the middle of the night with these awful night terrors, and be disoriented to where they were. So talking about what makes the nightmares worse, you know, watching certain shows before bed, medications, lack of medications, alcohol, what is it that may make these nightmares become more vivid and more frequently, sometimes just stress can make that happen. But also having a plan in place for okay, if you wake up with a night terror, what can you do to mitigate this reaction? Sometimes you can create a nightmare if you go to bed and you're so afraid you're going to have a nightmare, you either A, may not sleep well, or B, you may kind of focus on it so much that you talk yourself into it. So one of the things that we would do with our patients that had the night terrors, they would always be able to have a nightlight in their room. So they could see they could get oriented visually as soon as they woke up. We would have them, you know, keep a light by their bed that they could turn on, we would have them make sure before they went to bed, they had relaxed and focused on something other than the trauma and other than worrying about having a nightmare. Obviously, the more stress they were under or if they happened to be dealing with this issue in group, in therapy at that point in time, we knew that that might bring it more to the surface. Being aware that okay, it might happen and how to deal with it cognitively was so helpful to a lot of people because they felt a little bit more in control, even if they did have a nightmare. When they woke up, they felt like they were able to kind of get back in contact with the immediate time and place a little easier. Symptoms of avoidance and emotional numbing, avoiding reminders of the trauma. Well, it makes sense. If something reminds you of the trauma, you're not going to want to go back and remember it because that was probably one of the most horrible days in your life. Totally makes sense. Now, if you start trying to avoid every single reminder and every reminder of a reminder and every reminder of a reminder of a reminder, then eventually you're not going to be able to go anywhere. We need to help people identify what these reminders mean and figure out how they can deal with them in a meaningful way.  So we need to say, okay, what is it that you're going to do to help you stay focused in the present? And we're going to deal with all the stuff around that situation, no doubt. But in the present, how can you handle it if you have to see a pool? If you see a advertisement online for people who build pools, anything that may trigger some of your symptoms, how can you deal with that? Inability to remember important aspects of the trauma. You know, this is a cool thing about our brains. If it's something that is too overwhelming, and obviously this is not, this is only my own opinion and my own observation from working with clients over the years, people don't always remember everything right away. But it seems like once they're strong enough, the brain kind of gives them a little bit and says, okay, you're strong enough, you can handle this much now. And you can handle this much now. And over time, they start to fill in the gaps. But it's almost like there's a floodgate there and somebody going, you can't handle everything. Encouraging patients to be kind to themselves, if they can't remember important aspects of the trauma, they will come.  This is the way it is for a lot of people who can't remember all the aspects of a trauma. Two things can happen. They can get frustrated, which just increases the rumination on the PTSD symptoms and frustration and feelings of helplessness and all that negative stuff. Or they may inadvertently start to make up stuff to fill in the blanks. I would rather them be kind to themselves and go, okay, well, when I'm ready to remember, I'll remember. And that is really hard for a lot of people to kind of wrap their head around that they don't have to remember every aspect. I want them to stay focused in the present. I want them to tell me, how is this trauma affecting you right now? How is it impacting your daily life? And then, you know, the other aspects, the details may or may not be important in resolving the trauma. But let's focus on right now. And then as you feel stronger, as you feel happier, as your coping skills get stronger, then, you know, we may revisit it. Loss of interest in activities and life in general. If you are constantly hyper-vigilant, if you are constantly being reminded of the trauma, if you're stuck back at that awful day, at that awful time, yeah, it's going to be hard to be interested in other activities and enjoy life. There's going to be some depression there. Trauma by virtue of the fact that it doesn't fit with our schema about life. And trauma by virtue of the fact that it tends to take away power results in a grief process of some sort. And keeping that in the back of our mind is helpful in understanding and conceptualizing what's going on with clients. Feeling detached from others or emotionally numb. Well, if you've seen people die, if you have been threatened by other people, then, yeah, it makes sense that it's going to be, you don't want to feel, you don't want to connect too much. You may not want to feel at all because if you start feeling you may not be able to stop. Totally makes sense to me. Now, is that a way to live life? No, you know, but it totally makes sense when you're overwhelmed by this flood of emotions that you may want to turn that off for a little while because that was overwhelming. Encouraging clients to take it step at a time. And then a sense of a limited future. They saw something horrific. They were threatened with death or they saw somebody die. So yeah, they may start questioning how much longer am I going to live? You know, if I go outside, well, am I going to get hit by a car? Definitely thoughts that are going to go through people's heads. We want to focus on realistically. What is the probability that this is going to happen now? There may be a lot of things that happen. And they're at the forefront of your mind. And we call this the availability heuristic. Plane crashes, for example. We hear about plane crashes. And people are afraid to fly on planes because they think planes crash all the time. In reality, thousands, tens of thousands of planes fly every single day. But we don't hear about the ones that successfully land. We only hear about the ones that crash. And when you look up the statistics, it's more it's safer to fly than it is to drive and yada, yada, yada. Looking at the objective and the factual nature instead of, well, this is the thing that sticks out most in my mind. Therefore, it must be true. We need to work on addressing that cognitive fallacy. When we're working with people who are feeling emotionally numb, ask them, what do you do to try to enjoy life? What kind of makes you happy sometimes now? Or what would happen if you were happy? Survivors guilt is huge. Some people feel guilty for being happy. Some people feel guilty for going on with their lives because someone else lost theirs. Or someone else lost something. Working through that with the client is going to be important in recovery. Increased arousal, difficulty falling or staying asleep? Well, if you perceived helplessness, if you perceived a threat, even if you weren't asleep when you perceived that threat, guess what? Your body knows that when you're asleep, you're vulnerable. And you don't ever, ever want to be vulnerable again. It makes logical sense. You know, from a very primitive standpoint, it makes logical sense. So now we have to kick in our higher order thinking and go, all right, if I fall asleep, how likely is it that I am going to be traumatized again? Now there's a little caveat with that, because if people are also plagued by persistent nightmares, then not only are they worried about external threats, but they're worried about the threats in their dreams. We do need to pay attention to that and not minimize what sleep means to people and in what ways they may be vulnerable. It doesn't mean we can't deal with it. Helping them understand the function of increased arousal, helping them create an environment where they're safe, and helping them create an environment where if they do have a nightmare, they wake up and they can easily anchor themselves to the present time are all interventions that are pretty useful for people.  They have to have the TV on and eventually they'll just kind of pass out.  Developing a good sleep routine and helping people identify what may be making them fearful of just turning out the lights and going to sleep will be helpful in the treatment process because we know that insufficient or poor quality sleep will lead to irritability and outbursts of anger. Now you've already got somebody who's wound tight. They're wound up, they're hypervigilant, whatever you want to call it, which is making it hard to fall asleep. And then when they start getting exhausted and they're still hypervigilant, irritability, anger, outbursts are just going to become more prominent because they're exhausted. They can't sleep, they can't relax, they're feeling helpless, they're feeling a little hopeless at this point. Don't blame them. I got that. So how can we work on this? How can we help you get the rest you need and the relaxation you need? And we can talk about exercise. We can talk about medication. We can talk about any variety of things that people think might help them be able to do the day to day things that most people take for granted, like sleep, concentrate. When you are hypervigilant, when you are aroused, when you are constantly on alert for a threat, you can't focus on one thing.  If you're not scanning with your eyes, you're scanning with your ears, you're constantly aware of what's going on. It's exhausting. So you have being exhausted when you're awake, then coupled with not being able to fall asleep, it's old after a while. And then this jumpiness and easily startled. When things go bump, when a car backfires, when somebody screams, whatever the trigger is for that person, it can start to be generalized. One of the things that we notice is that the more different whatever it was that startled you is than your current situation, the more of a startled response there is. So for example, if you are in the library and somebody drops a bunch of books on the floor and it makes a loud crash, you're probably going to jump three feet out of the chair. If you are in the middle of a busy restaurant and somebody drops, you know, a tray of glasses, likely the noise level in the restaurant was high enough and you were not so focused on whatever you were doing that is likely that your startled response is going to be lower. Helping people understand that that's just the brain's way of kind of letting you know that something just happened and there was a dramatic change can help people deal with this jumpiness. And there's a lot of other things we're going to talk about, but we're seeing that the brain is saying we're on alert, whatever this was, it was unexpected. So I don't know how to plan for it, which means I'm just going to stay on constant alert because I want to live. That's what it comes down to. Other common symptoms of PTSD, anger and irritability in general, guilt, shame or self-blame. This can be survivor's guilt or this can be guilt, you know, if you did something or the person thinks they did something that they were told not to do, maybe they were told not to drink and drive and they drank and drive drove and they ended up getting into a car accident and seriously injuring someone or killing someone or they were told not to talk to strangers and they talked to strangers and got kidnapped or they, you know, you can hypothesize and all the different oars you get the point. People may feel guilty because somehow they may feel that either whatever happened was their fault or they should have been able to prevent it or they should have been able, they should have been the one that died or got injured and the other person should have lived. Substance abuse, numb it out, try to make it go away. It's kind of like putting your fingers in your ears and saying na na na na na na na na. It numbs it, it doesn't fix it as soon as you start to sober up, it's still there. Depression and hopelessness, you're exhausted, you're hypervigilant all the time and you can't figure out how to make it stop. It can be exhausting which can lead to suicidal thoughts and feelings. The guilt, the shame, the self-blame coupled with hopelessness and helplessness can be overwhelming and at a certain point people may not feel like they can take it anymore, not a single another second. Feeling alienated and alone because a lot of people don't get it. They don't understand why this is still bothering you. They don't understand why you jump so high. They don't understand other things. Part of it is because with a lot of the patients I've worked with, it's because they haven't understood enough about the whys and the what's to be able to explain it. Once they understand it and they can explain it, then other people are generally pretty supportive. Feelings of mistrust and betrayal make sense. If whatever happened caused you to feel threatened, then you're either going to not trust yourself and not trust your own instincts and or you're not going to trust other people. That is a really depressing life to live in or place to be in when you can't trust anyone or anything. And then headache, stomachs, problems, and chest pain, panic attacks, anxiety, constant stress. It starts wearing on the body after a while and those neurochemicals start to get wonky. You know that's my favorite word. So why do some people develop PTSD and others don't? We don't know. That's the short version. Okay, class over. No kidding. Similarity to the victim or being the victim. Obviously if you're the victim, then you experience the helplessness or the horror. We've also seen that people who are similar to the victim, if a law enforcement officer responds to a call where a small child was beaten to death. If that law enforcement officer is also apparent, then it is meaningful and hurtful and devastating to them on a whole other way because they start seeing their child in that position. What would they do if it was their child?  So if there's a similarity to the victim, people may internalize the trauma a little bit more. If it's closer to your safe zone, it's easier to say that something happens to those people over there. As it is, just then it is to say, this happened in my own neighborhood, or these people are just like me. That's scary. Because that means it's not us versus them. That means it's your part of us, which means you could be vulnerable. Social support after the trauma, if there is none, it's a problem. Most people within 24 hours, that's our key window, 48 on the outside, but 24 hours is when people are still have that raw nerve and can still articulate some of the things that are going on. They haven't started compartmentalizing and packing stuff up in the back of their mind. It's vital to have social support after the trauma. It doesn't mean and this is important. It doesn't mean that it's a time where somebody needs to go through every gory detail of what happened. That's not social support. Social support is somebody being there going, whatever you went through really, really sucked. And I'm here, you want to scream, scream, you want to cry, cry, you just want to sit, that's fine too. But I'm here to let you know that you're not alone and you're safe. If there's a history of mental health problems, if they already have a tendency to become depressed or have anxiety or if they have a history of PTSD or substance abuse, the likelihood of developing post traumatic stress symptoms, not being able to deal with this huge trauma is increased. And then the number of stressors in the past six months and in other presentations, we've talked about vulnerabilities. And this is really what we're looking at here. If somebody is already worn down, if somebody is already feeling a little out of control or a little disempowered, if somebody's already exhausted and they don't have the emotional energy to do much more than get up and kind of blindly go through the day, then when this happens, they may not have the energy reserved, they may not have it in them to respond as aggressively or as robustly as they may need to in order to prevent ongoing depression, anxiety and hypervigilance. So when we're assessing somebody with PTSD, ask them, you know, tell me about the situation. If you weren't the victim, how were you similar to the victim? Obviously, if they were the victim, that's the obvious place to start.  What is it that you see in people? What is it you see in your environment that is similar to what happened? Because these may be triggers. These are things we can potentially counter condition. But I want to know what's triggering your symptoms right now. What was helpful for people to do after the trauma or what do you wish people would have done? This can give you an idea about how much social support they had and what kind of social support they want or need. And who can you rely on? Who can you rely on to do those things now? Who are your social supports? And if they say nobody, then obviously that's something that we probably need to look at. What can you do to take back your safe zones? And safe zones are really those places where you should feel comfortable, home, in the car, driving to and from work, going to the store, when you're at work. How can you take back those safe zones so you feel safe in those places? For example, going to the store at 11 o'clock at night and parking way out in the nether regions of the parking lot, probably not a way to take back a safe zone. Looking for a front parking lot, or even not going to the store at 11 o'clock at night. Those are common sense interventions to make sure that you stay safe, but also making sure that the environment is set up in a way that you feel safe, that you don't feel like you constantly have to listen for every creek, for every bang, for every footstep. How can you protect yourself from whatever it was that happened in the future? Sometimes this is just taking good safety precautions, maybe taking a self-defense class, maybe you could hypothesize and brainstorm with people, what is it that you need to do so you can feel empowered and safe? And then encouraging people to look at how the experience changed, how they view things. Do they now view the world as a scarier place? Do they now view certain situations or certain places as scary, threatening, undesirable? What is important to you now? Did that change? For some people, they'll say, well, my family is the utmost importance now. I need to focus on them. Some people have different changes in their priorities as a result of the trauma. And then how will you live your life now? And this is an open-ended, one of those sort of vague questions, to see kind of where they're going and where their head space is as far as whether they think they're safe, whether they still have hope, future directions, and get an idea about where they want to go from where they are right now. Sleep. We need to talk with people about sleep. If they're not sleeping well, there's going to be a problem because it balances their neurochemicals, helps to reduce cortisol and may improve adrenal fatigue. We know that when the central nervous system is constantly kind of on guard, the body gets exhausted. And you can only secrete adrenaline for so long before the body just goes, I need a break. I can't take it anymore. So people need to sleep. That way, their adrenals don't get fatigued. That way, they can respond to stress appropriately, yada, yada, yada. Adrenal fatigue leads to feelings of depression and anxiety.  This is not brain surgery. There are very simple things they can do to start feeling better. Safety, environmental safety. Obviously, the common sense things like locking the doors at night and not going out, jogging on a dark path with nobody around at 11 o'clock at night, those are things that are important. But there are also situations where you feel more under stress. Law enforcement officers, you'll notice especially career law enforcement officers will never sit with their back to the door. You can kind of spot the cops in a room by how many guys are sitting with their back to the wall and looking at the door. That helps because you're not worried about who's coming up behind you. You're not on guard. Most of us, even if we are in a safe restaurant in a safe part of town with friends, we're a little bit more on guard when we can't see what's going on behind us or if somebody walks up closely behind us. Paying attention to that. Sleeping. Back to sleeping again.  Feng Shui will say a lot of other reasons for it. But if you can't see one of the entrances or exits from your room it will likely add extra stress if you're already feeling anxious. Being able to see the door and see the windows, very helpful. Keeping a nightlight on if that helps you stay anchored. If that helps you feel a little bit more secure. Now we've talked before about the fact that the levels of melatonin go down the lighter your room is. So you don't want to have one of those 40 watt bulbs going all night long. Once your eyes adjust to the dark and when you're sleeping they adjust to the dark so when you wake up it won't be as big of a deal. A five watt bulb is more than enough. It's more than enough to illuminate the room so you can see pretty much everything around you. Anchoring. So when you wake up you can get in the present moment. What helps you stay anchored and this is helpful also with people who have dementia. If they can figure out where they are and when they are it's really helpful. Current pictures, lights, the ability to turn on a brighter light if the need arises. What else can help you stay focused in the present moment so you can see that you are in your safe bedroom. You're not in the middle of Afghanistan. You're not in the bedroom that you grew up in where you were constantly abused. What is it that can help you stay now? Some people need a safety item. You know I have a dog and actually I have multiple dogs but my dogs at least one of them sleeps in the room with me every night and that helps me feel safe when I go to sleep. Stimuli. Be aware of sounds, smells and sights that may help you sleep or that may get in the way of sleep. If you leave the TV on which is not recommended it could hinder your sleep because there are loud commercials. There are potentially cars backfiring online. There are potentially gunfights online. Who knows what you're going to hear when you're in that sleep state. You can turn on if you don't like sleeping in the ultimate quietness or maybe you're in a situation where you're not able to make it quiet. You live in an apartment complex or a busy city. White noise. You can get the apps for your iPhone. You can get the little devices that you put next to your bed where you hear jungle sounds, babbling brooks, whale calls, whatever does it for you. Something that can help you lull yourself to sleep. Smells. You want them to be not triggering smells. Things that make you happy. Things that make you calm. Not smells that remind you of the trauma or somewhere you don't want to be. And then sights. What can you see when you wake up? What do you see? What do you see when you're going to sleep? Remember when you were little or your children were little and they thought the boogeyman lived under the bed. Having them feel safe, part of that was a matter of checking the room, making sure that they had a night light sometimes, helping them feel safe so they could go to sleep.  Watching monsters ink before bed, not a good idea. Routine. Help people set a routine so their body knows when it's time to sleep and starts secreting melatonin. If they are laying in bed going, I really need to go to sleep. I'm afraid I'm going to have a nightmare. I really need to go to sleep. They're never going to get to sleep. So let's find ways to release stress and tension, get ready for bed, feel safe, and able to go to sleep. Finally, medication. Some people end up needing it, at least in the beginning, in order to calm down enough to sleep. And that's up to them and their doctor and, you know, whether they want to look at something like melatonin or they want to go with something like lunesta or maybe an atypical antipsychotic if they've got other symptoms going on. There are a host of options for medication, personal opinion. If that becomes something they rely on constantly to sleep, then there's probably some underlying stuff that needs to be dealt with. My goal is for people to live their highest quality of life possible. And some things that some people have seen, soldiers have seen, people who've been horrifically abused have seen. You know, I don't know that I'd ever be able to go to sleep with those memories in my head. So I am not going to say, well, you should only do medication for a short period. That's between them and their doctor and what's going to get them the highest quality of life. Encourage people to brainstorm different ways they can create safety at home. What makes them feel safe? I came home the other day and I don't remember where I'd been, but I had foolishly left one of the doors unlocked and nobody else was home. And I walked in now. Remember, I said, I've got four dogs. So the chances of anybody even going in there are slim to none, but I was still nervous. So we cleared the house.   And we went and we looked everywhere and in every closet and that made me feel comfortable. At that point, I, you know, I had locked the doors and I knew nobody else was in there and I was good. What is it that's going to help people feel safe? Hopefully, they won't have to clear their house every night. But, you know, if they have a dog, if they turn on the outside lights before they go to bed, if they, you know, and let them fill in the blanks. At night, I can't stand having the blind open at night. It just gives me this creepy feeling because I can't see out. That makes me feel hypervigilant and nervous. Other people, they don't really care. They have never had curtains because they lived in the country and, you know, I live in the country now, but I still don't want the deer seeing me walking around in my nightgown. How can they feel safe at night? What do they need to do differently when they're in the car locking the doors? What else can make people feel safe so they feel like they can get from one place to another without feeling threatened? Sometimes in the car, it's not just about somebody carjacking you, but it's about getting hit. It's about getting rear-ended. So, maybe not driving in high traffic times of the day, maybe taking back roads to get to and from work, whatever does it for people. And then at your office, how do you create safety? Not sitting with your back to the door? It's a good step.   That way you can see behind you. So, you're never surprised. People need non-judgmental social support that's available 24-7. When they're initially dealing with post-traumatic stress, it's important that they have somebody who can help them get grounded. Somebody that's empathetic and not judgmental. Not, well, you should be over this by now, or that happened over in Afghanistan. Why are you still letting it bother you now? Or you should feel this way, or you shouldn't feel this way. None of that is helpful. The person feels how they feel and they need to work through it. In the midst of a post-traumatic crisis, when somebody is really struggling, they may need some help meeting their health and safety needs. They may need some help remembering to bathe, getting to doctor's appointments. They may need somebody to sleep on their couch so they can get a couple hours' sleep and feel safe. That's okay. What is it that's going to help you and who can help you do it? Right after a trauma, and this is more acute stress disorder than PTSD, people aren't remembering much. And when people start PTSD treatment, if they start revisiting the trauma, or even just during the assessment talking about it, can throw them into enough of a tailspin that they're in a crisis situation. Write things down. Don't expect them to remember it. Don't say, I want you to do these three things before the next session and let them walk out. Write it down on a piece of paper so they have it and they can look at it when they get home. Some things you logically know aren't threatening still evoke a startle response. I talked about the cabinet banging. We have wood floors on the main floor of our house and four dogs. So I know good and well that it's going to be noisy once in a while, but if I am in the midst of working on a presentation and the house is dead silent and all of a sudden rain is sees a leaf blow by and starts barking, I usually jump. That's a startle response.  And then they would get frustrated that they got startled. And then they would get angry that they were frustrated and they just worked themselves up into a negative tizzy, if you will. Encourage people to acknowledge the event. The dog barked. Something must have blown by. Somebody slammed a door. Be kind to yourself. Don't get into that negative tizzy. Say, all right, I jumped, you know, no threat. Go back to what I was doing. Recognize the value of the startle response. It protected me. Now it may be a little bit over aggressive, but it did protect me. Identify times when your startle response might be greater, when you're tired, when you are in a really quiet environment, when you are in a stressful or in an environment where you perceive yourself to be unsafe. If I'm sitting in the middle of the police station, I am going to be a little jumpier probably than I am if I am sitting in the middle of the library. Understanding when you're on edge and when your startle response is going to be stronger. And then identify ways to mitigate it. When it happens, what do you do? How do you deal with it?  One thing that is very helpful with people with PTSD is cognitive processing therapy. And in your class, I've put a link to an online class by MCSU, I think. Middle South Carolina University, maybe. Anyway, it is an excellent class that walks you through a process of cognitive processing therapy. One of the tools that they use in CPT is called the challenging questions worksheet. And it says, alright, what happened? Right now, what happened? We're not talking about the trauma. What happened right now? Somebody slammed the door. What's the belief? What are those automatic thoughts or automatic beliefs that made you get upset? You got yourself all into a tizzy. Then we go into, is this belief based on facts? Is there objective evidence that you are under a threat or feelings? It brought up those feelings from the past. How reliable is the source? Are you a reliable resource right now? Or are you thinking with feeling focused? Are you, is your judgment clouded? Are you using extreme words like this always happens or I'm never safe? Is the belief based on only part of the picture? Nobody can ever be trusted because Tom betrayed me. Well, if Tom betrayed you, that's one person. So I don't think we can say nobody can ever be trusted. In what ways does this does this belief protect you because you're holding it for a reason? There's a rewarding factor to it somewhere. And generally, that's protection. And in what ways does this belief impair your life? Do you want to hold on to this extreme belief? Or is it keeping you from being happy and enjoying your life? And finally, how can you best use your energy? Are you going to use it to fuel this belief and make sure that nobody ever hurts you again? Or are you going to use it to deal with this particular aspect so you can enjoy all the other areas of your life? Most common cognitive errors and PTSD are overgeneralization, taking that car accident on the interstate and feeling like you can never be safe on any interstate or every semi truck is a potential threat. The control fallacy, thinking you could have controlled it, you could have fixed it, you should have been able to do something or thinking that you could have changed whatever it was. Taking responsibility, trying to think that in that situation, you did have power that you chose not to use. In reality, 99% of the time, there is nothing the person could have done differently. There is something they could do differently. Now maybe they may choose different courses of action. But a lot of times traumas are unpredictable. And there was nothing you could have really done to prepare for it. All or nothing thinking, catastrophizing, grandiosity, and personalization. It's all about me. It's all my fault. Everybody is, because this happened, everybody hates me, encouraging people to challenge these cognitive errors and figure out, you know, if everybody's upset, why is it? Is it all about you or not? You can't squeeze blood from a turnip. So we have to encourage people to take care of their stress levels and all other areas of their life. If they're working on their PTSD, if they're working on their trauma issues, that's where the lion share their energy is going to go right now. So they need to try to de-stress the other areas as much as possible. Therapy is a full-time job. You may only show up to counseling once a week, but therapy is a full-time job. So and I mean that for the clients, not for us. Of course, it's a full-time job for us. But they need to pay attention to their emotional health, their physical health, and they need to get some positive socialization. I said earlier that traumas necessitate some sort of a loss, loss of control, a loss of sense of safety, a loss of hope, a loss of idealism. Loss of life, obviously, there are those tangible losses. So we need to help people identify what they lost as a result of the grief or as a result of the trauma and how they can restructure that. Okay, they may have lost control over that particular situation. How can we reframe that so that's just situational instead of they have lost control over everything all the time?  So we need to look at the anger, the depression, and what does it look like to accept that this trauma happened? For each loss, ask people, what about this loss makes you angry? If you lost control, if you lost your hope, what makes you angry about that? How can you get your hope back or deal with it in a healthy way?  It's pushing people away, it's keeping you from being hurt again. What are you still protecting yourself from and how can you integrate that so you don't have to feel threatened all the time? And then remembering that depression signals a sense of hopelessness or helplessness. So if you've got all this anger going on and you feel like you need to be protected, yeah, you can feel kind of helpless. So let's look at what you can be hopeful about and where you feel empowered and how you can create the situation where you don't feel like you need to be protected all the time. How can you be empowered to take control back of your life and of your feelings? So PTSD can be from a single event or multiple ongoing stretchers. Traumatic events can change people's beliefs about the world in extreme ways. Instead of being totally safe and wonderful, it's a devastatingly scary place. For some people, understanding the function of the symptoms can help them desensitize because they understand that is their brain's reaction trying to protect them and then they can kick in their higher order thinking and say, you know, I'm not in danger right now. It can help them modify their beliefs about people, about things, about life and it can help them make positive, mindful choices so they're not vulnerable to PTSD stressors, PTSD reactions or PTSD triggers.


This 2015 Chevy Silverado 2500 Crew Cab Short Box is stock number 12294Z. We are here at Summit Automotive in Fond du Lac, Wisconsin near new and used heavy-duty truck headquarters. This 2015 really good-looking Chevy 2500 has the 6.6-liter Duramax diesel with the LML engine, which pumps out 397 horsepower. This truck has been fully-safetyed and inspected by our service shop for the state of Wisconsin inspection process. It has a fresh oil and filter change, all the fluids have been checked and topped off, and this truck is 100% ready to go. Summit White is the color. We're going to go inside, outside, started up, check out under the hood in this video. We shoot all of our videos in 1080p, 60 frames per second, so if you have the HD capabilities on your computer, tablet, smart phone, or television, I highly recommend turning them on right now because it is your best way to check out the quality, condition, and options of the truck before seeing it in person. And if you like how we do videos here and want to subscribe to our YouTube channel, the upper right hand part of the screen is a subscribe button. Click that and then click the bell notifications and you'll get updated every time we do videos here at Summit. This one comes with fuel 22-inch painted alloy rims, and it has Nitto Recon Grappler AT tires. These are 35, I'm sorry, 37x13.5 R22LTs, and they look like they are just about brand new in the front. Still have a little bit of the wear knobs on them, so I'd say 99% of the tread left on those tires. Frame and underbody is in really nice shape. It does have a rough country suspension lift. I do apologize for the pounding. We are doing some construction in the room next door, so that is what you're hearing. Front fenders in excellent shape. Comes with the projector lamp headlamps. Front bumper and lower valance are in excellent shape as well. No major dents or dings on there. The hood is in excellent condition as well. No dents or dings on that, and you do get the chrome-trimmed grille. Passengers side front fender. Pretty nice shape. And the passengers side rim. Pretty nice condition. Just a couple little scuffs on the way outer edge. As you go down this side of the truck, take note of how clean the body is, how reflective and mirror-like that paint is. We take these HD videos, so if you are far away, or even if you're close by and just cannot make the trip down, but you're still interested in purchasing the truck, you can see the truck here, the truck and of confidence in the vehicle that you're looking at. Before you even get here, so when you do get here, there's absolutely no surprises. You can make a smart and informed buying decision from wherever you're at. And if this video helps you make that buying decision, let your salesman know that you saw the video and that Brett sent you. There's one little scuff on the back rim here as well. The back tires have just about as much tread as the front tires as well. You can still see a little wear knob on there. Frame and underbody, very nice condition. Looks that way all the way underneath, looks really good. Has power running boards, cab corners and lower rockers. I didn't see any corrosion on them. And this box side is in pretty nice shape as well. Coming around to the back, rear bumper is in nice condition. Does have the rear bumper steps, full towing package, which includes a receiver hitch, four pin and seven pin wiring. The tailgate is in really nice condition. I didn't see any dents or dings on there. Has a shock down assist tailgate, and it does come with a Rhino liner spray and bed liner. Beds in really nice condition. I didn't see any major dents or dings back there. Tailgate shuts nice and solidly. And as you go down the driver's side just as clean as a passenger's side, I didn't see any major dents or dings on the box. And for full disclosure, this back rim is in pretty nice shape as well. Down the rest of the side of the truck, looks really good. Does have power mirrors, driver's side blind spot mirror.  No rips, no tears on the seats, they're in really nice shape. I believe it has lumbar and driver's side height adjust. Maybe that's just for the backrest. I think it has lumbar. Factory all-weather floor mats, auto headlamps turned out four-wheel drive. Factory brake controller, tilt steering wheel. Power windows, power locks, and power mirrors. You can see that that running board came down nicely, and those are AMP research running boards. Pretty much the best name in power running board technology. We'll hop inside, turn the ignition on, check out the radio, miles, and everything that this truck has to offer on the interior. 64,198 miles, you do get a digital speedometer, compass display, and the instrument cluster is very nice and clean. Comes with a leather-wrapped steering wheel, Bluetooth and information center controls on the right, cruise controls on the left, and it does have audio controls on the back of the steering wheel. This one's going to come with the Allison six-speed automatic transmission with the optional tap shift, AM, FM, and Sirius satellite radio capabilities on here. And you can connect your Bluetooth phone to this CD player. Climate controls, those outside mirrors are heated. Do you get stability control? Cargo lamps, that's for your factory. Brake, passenger side format, and seat are in excellent condition. No rips or tears on there. Smells very clean inside this truck. I don't think it's ever been smoked in. The headliner is in nice shape, and you do get map lights up there. On-star capabilities in the rear view mirror, and SOS capabilities as well. We'll take a quick look at the back seats, and then we'll start it up and take a look under the hood. Back seats are in excellent shape as well. No rips or tears back here. Fixed glass rear window. These seats fold up for extra storage. You can see just how nice and clean carpeting and floor mats are back here. And this truck does come with side curtain airbags. Bottoms of the doors all look really good. And we'll start it up and take a look under the hood. Starts right up. No check engine lights or anything like that. I would personally like to thank you for checking out the video today. And hopefully from this HD video you will have been able to verify the quality and condition of this truck inside and out. Under the hood we have the 6.6 liter Duramax diesel engine. Engine bay is very clean, runs very smooth. Once again this truck has been fully safe and inspected by our service shop. It has a fresh oil and filter change. All the fluids have been checked and topped off. This truck has like new tires on it. And is 100% ready to go. I would highly recommend this truck from a quality and condition standpoint. And to see more pictures of this truck or one of our other 450 new and used cars, trucks, SUVs, minivans, Wranglers, half tons, 3 quarter tons, one tons. You name it we got it go to that website right there www.SummitAuto.com Full pictures and descriptions of every single vehicle from two locations. All at SummitAuto.com. If you'd like to check out more HD videos you can go to YouTube.com. So I have Summit Auto remember to like, subscribe and share on this video and all the videos that you see there. Click the bell notifications you'll get updates on the videos we do each and every day here at Summit Auto. In fact in a second you will see a link to subscribe to our YouTube channel in the upper left to link to more Silverado 2500 truck videos like this one in the upper right. Link to this vehicle on our website in the lower left and a link to one of our latest YouTube videos in the lower right. Click those check us out and we're super excited to help you with this ultra clean 2015 Chevy Silverado 2500 Crew Cab Short Box 1LT in Summit White Clear Coat. Thanks again for checking out the video and remember to like, subscribe and share.


You guys have done a tremendous job in the last few months, getting near back ship shape and in good health. I'm wondering if you could tell us what you think the odds are that eventually you'll be able to repressurize and use the Spectre module. Virtually the commander is behind us and he's doing his exercise right now on the treadmill, so he won't be able to talk, but it has been a busy time and a great deal of repair work's been done and I can tell you that these cosmonauts, the sanatorium, are just amazing at their ability to replace systems and work hard. It's been spectacular to watch and to help. Maybe just along those lines, maybe you or Mr. Vina Gradov could answer the question about Spectre. I mean, you guys must talk about it. Do you think the odds are any good that eventually you'll be able to recover that module? I have options to revitalize the Spectre module. Unfortunately, we'll probably not have enough time to complete it during our mission. Practically all hardware is ready for it. All equipment and repair tools to find the leak and to try to repressurize the Spectre module. The question for Commander Wilkett. Sir, on this Super Bowl for Sunday there doesn't really seem to be a corner of the United States you can't go without hearing a lot about all that's going on in Washington in recent days. I was just curious if there was a corner of the solar system where you don't find out what's going on in Washington if you guys are able to keep up or if that's any kind of a distraction for you. Well, actually we get news from home each day on the version of email that we have up here. So, you know, it's such a mental break to read news from home. We're able to keep up with what goes on on the sports field and in Washington. Is this Bill? Is this Bill Harwood? Yes, it is, Jerry. Go ahead. I just wanted to say hello and hope things are nice down in Florida. Well, they are indeed. Thank you. And I'd like to turn to David Wolf and Andy Thomas briefly.  Just wondering what you're looking forward to the most when you get your feet back down on the ground if it's a specific food or drink or just seeing people or what's on your menu or things to do. All of the above, Bill. Everything I think of, even driving my car up to a stop and go and walking in and getting a coffee, every little thing that I think of is something I can't wait to go do. Earth is a wonderful place. It's time to pass the baton to Andy. He's a very capable astronaut and he's ready for an experience of his life. It'll be tough and it'll be great. I got working aboard Mira for four months. Obviously we did a lot of training to get there, but were there any major surprises? We were surprised at just how much work it really is. We really work from night to night, say nine in the morning until midnight, every day, seven days a week, holidays included for the most part. And that's what it takes to really operate a space station and conduct a full science program. And it really didn't hurt. Once you get to expect that type of work level, it's just what you do in space. What about food, David? Is there anything in particular you're looking forward to, a pizza, a cold beer, anything like that? I've requested a pizza with pepperoni and mushroom and I think a few beverages will go along fine with that. And one last word for you, sir, for right now. A lot of pundits and politicians, of course, before you launched back in September, I recommend that against sending you to Mira arguing that it wasn't safe. What would you say to those folks now, four months later with Mira and the condition it's currently in? I really appreciate that they looked out for us and I think their questions were very good. And what we saw was our system working properly, our system of checks and balances. They came up with the right answer and I'm glad we're here. I'm glad Andy's staying and we're getting more than we ever expected out of phase one. And we can look forward to a big benefit as we move into the International Space Station later this year. For Andy Thomas, you said yesterday when you came into the Mira Core module that as you looked around, you realized there was still quite a bit to learn despite your training. What are your first impressions of the station now that you've been there for a day? What sort of surprises have you seen? The thing that strikes me the most is, unlike the training modules which I saw in Russia, there's awful lot of equipment stored on the walls and on the floor and the ceiling in here. There's a consequence there's not as much space. And that's the thing I'm going to notice the most I think is there's not as much working volume as I'd anticipated. You know, I think most folks going to Antarctica for an extended stay or certainly doing what you're doing would have some sense of trepidation, I guess, when you watch Endeavour pull away in a couple of days. Have you given that any thought or you think you're pretty well psychologically prepared to embark on what really does amount to isolation and sort of a hardship assignment? Well, you're right. It is going to be isolated. You know, you think you're psychologically prepared, but things often turn around and surprise you. I'll have to give you my responses to how I feel after the event of seeing Endeavour leave, but I think it's going to be tough. One more here.  What are you going to do on mirror when you do catch the occasional few hours when you've got it to yourself and have some spare time? Hopefully, we'll get some spare time. We've got music up here. We've got CDs. We've got CD-ROMs. We've got video films. So we've got those as entertainment. We've got exercise machines up here, so we can't exercise. There's even a guitar up here so that we can play guitar if we get a chance. A question really to anyone. Probably, I guess, Commander Wilk. Senator Glenn flying in space in the fall, of course, has generated a lot of interest on the ground. Well, actually, this might be a good question for Dr. Wolfe. I was really wondering what your thoughts might be about the senator flying as a human being but also as a test subject for perhaps learning whatever could be learned from one person about the effects of weightlessness and aging and all of that. What are your thoughts about that? Well, of course, one of NASA's goals is to go to Mars and leave our Earth essentially permanently with colonies down the line. We have a lot to learn about that. But, of course, the effects of gravity are largely responsible for the whole form and function of our bodies. And by taking away and changing that variable, we can learn a great deal about how our bodies work on Earth. And it is one of the very important things that we do in space for the benefit of all mankind. With Senator Glenn, I mean, is that a good thing to do in your mind to send someone 77 years old up into space to do research with? Well, I guess back to your previous question, I did not know that Senator Glenn was going to fly or I know nothing about that. I've had very little news for the last three or four months. So someone else might be better able to answer that. I could answer for Dave and I. We would both be very happy to fly with Senator Glenn. Itty-tie, itty-play. Well, let me get back to Dave real quick for a second. One of the questions I meant to ask you earlier was that in the course of your four-month subboard mirror, if you ever had any moments where loneliness crept in or I won't say depression, but I mean, you are up there by yourself in a stranger in a strange land, if you will. Did you experience any of those emotions or was it pretty much a steady pace throughout? With some degree, yes, I did. And you have to keep a good, rational grip on your mind to hold those feelings at bay. And this is something Andy and I will be discussing and the fire crews helped me with that. And we're learning how to do that. It's somewhat of a language barrier where you can't express all the feelings you'd like to, even though we can communicate operationally quite well. So those feelings are a big part of this kind of a mission. And it would be a great privilege to fly with Senator Glenn for any of us. We're Super Bowl Sunday down here. I was wondering if any of the crew members would care to make a pick or say who the folks are pulling for up there. Well, I guess I could speak for the crew of Endeavour as well as the crew of the mirror but if there are one place that we're going to be besides the space that we're occupying right now to be sitting on the 50-yard line. Russian Information Agency News Oleg Lebedev. We all wish you success to complete the mission as for the Miya station and for the Endeavour. Question for Pavel Vinogradov. All of your mission started in August. Can you tell us what is left to do in the time remaining? I will start with the end of your question. By the end of our mission, we'll have a lot of work to do with the French astronaut who will be working together as to the final results of our expedition. I think it's too early to say about the results we had to do a lot outside of the Miya station. We replaced the solar arrays. We did two space walks and several walks to complete various technical experiments on board of the station. Those were very interesting. We also replaced a lot of onboard systems. I believe we did good housekeeping on the station. Right now it is functioning well and we hope that the following missions will be very resultful. And the next question again to you. During your walk on the Miya station, the central computers were not working for a while. What was the reason for those failures? Most likely the specialists will explain better what the reasons for the failures were. Most likely those are not the technical disadvantages of our particular system. I believe any kind of computer system is working in space than it is working on the ground. That deals with the level of radioactivity and also we have a lot of micro-orbital debris running around, electrical impact and so forth. I think there are ways to shield those systems and this is what we are doing. Of course our systems and any other systems, PCs, may fail. This is I think inevitable. And new PCs, new computer systems, new generation is on the way. And those will be working fine in space. Thank you very much. I have a question to Samurhan. What is your impression from Endeavour? Thank you for your question. My adaptation went very smooth and quick and on the first day of the flight I felt normal already and I want to say that right now I feel great. And I have a lot of experience working with my colleagues here. Also the launch was very beautiful of Endeavour. It was all smooth. Right now we are in space within two days. In space all systems were working fine and my personal impression of the views of the Earth and the space are unbelievable. I am very much impressed. Of course the view of the MIA station was quite impressive for me. Also when we docked and when we got into the station you know the size of the equipment and everything that was working, it was a great impression for me. I want to say to the guys, thank you for keeping the station in such a great shape. All systems are working perfectly. It was my dream to come to the MIA station and now my dream came true. I can see the station in a much better condition than I expected. And the last question to David Wolf. What are your impressions from the MIA station? Are you satisfied with your activities in Russian, please? What is your impression of your stay in the Russian space station MIA and please enter Russian if it is possible. Thank you. Everything was great. This is a great station, very able crew, very safe operations with this crew. We had a lot of work to do, a lot of fixing to do and we're continuing to working. Everything is fine, you know, and I feel great. Thank you very much. I'm giving the phone to my colleague from Interfax. Another thing, people who are working at the Mission Control Center are working great and it was a pleasure for me to find out how close they work with the crew. Everything was great. Hello, Interfax Andrej Curiev. I have a question to David Wolf. David, please tell me. What most interesting experiments you will be conducting within the four upcoming days? What kind of experiments you plan to conduct during the next four? You have the microphone and the score, no. Soon I will give the phone to Andy. My favorite was the short one. We are getting ready to bring the results of this experiment on the ground and Andy is going to continue working on some of it. This is a great experiment for the future of the people. Another question. A question to Pavel Vinogradov. Pavel, please tell us how do you assess the level of readiness of American astronauts for long duration missions? I have to say that all of them, without any exception, everybody who comes to the Miya Station I experienced astronauts. Most of them have experienced in space previously. For example, John Blaha. And now the people who come here, those are grown-up astronauts. They have great level of preparation. And as to the level of preparation of working with the experiments, I think this is the highest level of preparation possible. Of course, it is impossible to get ready for anything that can come upon the station and do the same way as we are training in Russia. We are training for three or five years. Of course, they have a little bit of less level of preparation in housekeeping for the Miya Station specifically, but this is another area. Also, the question to Andy. Do you believe you are an Australian astronaut or an American astronaut? Because you were born in Australia or an American astronaut. I am an international cosmonaut. Thank you very much. All the best to you.