Dr. Yaakov Freedman & Rabbi Dr. Benjy Epstein: Treating War-Time Trauma & Mindfulness

dear friends I want to thank you so much for joining me here this evening I am tremendously grateful to be here with my dear friend rev Dr Benji Epstein schita and our colleagues at amudim Israel who do fantastic work if I say nothing else just know that you should always reach out to amudim Israel if you have any questions especially as you are the primary care of Physicians on the front lines with that in mind let's go ahead and talk about acute stress disorder and how we should be evaluating and thinking about this with our patients you heard me say front lines and that's correct some of us are on the front lines in a very literal sense literally going and fighting aem's war with our hands and our guns and our nunchucks and whatever else hasem gave us for others of us we are in the clinic we are in the hospitals we are in our offices assessing patients who have experienced traumatic events whether personally or secondary trauma of having people they know and having watched way too much content on the internet and news with this in mind when we talk about acute stress disorder we're speaking about the initial reactions that a person experiences to traumatic events and traumatic news specifically we're talking about intrusive thoughts the idea that what a person has heard what A person has seen and experiened keeps on coming into their head and makes it difficult to focus on what they should be focusing on in in order to get through their day we're speaking about dissociation avoidance and arousal arousal is the fast heartbeat that many of our patients are feeling the tightness in their chest that they're feeling the shakiness in their hands their upset stomach their nausea their lack of appetite or their overeating all the physical symptoms associated with acute stress we're also speaking about the depressed dysphoric negative mood that people are experiencing as a result of these stressful experiences estimates say that about one in five people who have experienced such trauma will end up meeting criteria for what the American Psychiatric Association describ cries as acute stress disorder now what causes this certainly there's the traumatic event but there's also a genetic predisposition and as we know always there's the campfire kindling and then there's the matches on top of it some people are more likely to have a more severe reaction to stress and for those people who are coming to your office let's talk about what we need to do for them the main thing is frankly psychoeducation I want everybody to sit with their patients and normalize fear sadness and anger these are normal feelings given the amount of stress that our patients have experienced we should also encourage them to remember that they will likely end up persevering and being fine without further medical or psychological intervention the vast majority of people do not go on to develop psychiatric illness as a result of being part of a traumatic experience that's great news and we need to let our patients know that I encourage everybody to do a bit of what's called cognitive restructuring this is where we offer our patients a different perspective and allow them to think about things that help them to feel safe moving forwards because most of our patients are out of of Harm's Way in the immediate sense they have what to be grateful for and we should help them to find those things that allow them to feel safe calm and grateful in spite of everything that's happened as far as psychopharmacology this is always a big question by the family docs for the psychiatrists there is no overwhelming evidence for psychopharmacology interventions in acute stress disorders I'm saying it slow not because there's something wrong with me rather because you need to be careful not to overprescribe in these situations yes we should treat severe sleep disturbance and insomnia yes we should be aware that patients who have a history of depression and anxiety are at a greater risk of developing depression anxiety Panic mood disorders Psych breaks as a result of this stress but hopefully they are already in treatment with their psychiatrist and can be referred back to their psychiatrist for ongoing management or if there's a question of renewing medicines you can do that job of getting people started on the treatment that has worked for them in the past during times of tremendous distress we should be careful not to hand out benzodiazapine drugs Xanax Clon Ven and Other benzodiazapine Drugs which are highly addictive and are easily misused in certain cases we can hand out low doses of these medicines for a Tim limited perspective which can be quite helpful in allowing our patients to deal with acute stress and acute insomnia that being said a lot of education has to go into that telling our patients that these are not long-term treat treatments let's talk about preventing the development of PTSD after a traumatic event I'm going to go through seven specific coping skills that people who engage with them people who have these perspectives are able to keep in mind in order to avoid developing PTSD number one and most important family and Community Support barem that's big in our system we have a lot to offer as a kahila continuous contact and support from the people we know and love is critical number two talk about it people who are talking about what they've experienced with those whom they know and love are less likely to develop PTSD as somebody who's hearing what people are talking about it's important for us to note when to refer them for counseling thank God there are a lot of great resources out there for dealing with acute stress and PTSD there are great free resources and referral systems out there and again our colleagues at amudim Israel are happy to help you with that number three positive reframing people who keep perspective people who identify as a Survivor instead of a victim are significantly less likely to develop debilitating mental illness as a result of their trauma number four staying optimistic using positive emotions laughter smiling this works for keeping perspective number five spirituality meditation mindfulness practice connecting with our deep tradition of having a special one-on-one relationship with a kadosh baru is tremendously helpful for our patients number six giving back allowing people who have experienced trauma to connect with other people who have experienced similar tragedies in their lives so that they might strengthen each other and number seven staying strong holding the belief that you can survive through traumatic events this is something that we have to empower our patients to know you are going to make it you will bounce back and you will come back stronger The Power of Positive Thinking TR positive psychology 101 with that in mind I want to share a few closing recommendations to all of the family doctors pediatricians geriatricians and Primary Care Providers out there sobriety people who are using alcohol and drugs right now to deal with their symptoms are at Great risk of developing addiction people who are addicts in recovery are at tremendous risk of relapse we should give our patients strength by this and screen for substance use and refer to a professional when necessary and appropriate next psychopharmacology do not be afraid to contact am moodum to put you in touch with a psychiatrist who can provide curbside consults and guidance in these cases avoid the rush to provide psychopharmacology intervention unless you believe that there are acute reasons to do otherwise and should you have specific questions please don't hesitate to reach out to a colleague who is a psychiatrist if you do not have a colleague who's a psychiatrist we should be friends exercise cardiovascular exercise every morning allows one to keep their circadian rth rthm and to improve focus energy appetite throughout the day and to improve sleep at night time this is a must for all people CER how much more so individuals who have experienced acute stress and Trauma mindfulness practice RV Dr Benji Epstein will be teaching us specific mindfulness intervention shortly and I'm quite grateful for that we all have what to learn from his significant culturally appropriate expertise my man therapy there are specific therapies that are helpful as interventions in acute trauma CBT for trauma EMDR are fantastic psychodynamic Psychotherapy does not have a role in the acute setting as do many other interventions we should be quite careful to utilize professionals who have specific training to deal with these issues lastly social support we are that has always been the strength of the Jewish people if there is anything that this has taught us it is that no person has a right to Judaism themselves no person is too far removed from Judaism to be a part of us all we are is and we are there for each other and I could not be more grateful to be there for you and there with my colleagues again at amudim Israel who are doing a fantastic job of supporting CLA Israel during these challenging times peace and victory Shalom during this Ace sakov maintaining emotional stability and mindfulness is not only a personal virtue but it is also a way to contribute positively to the collective well-being by remaining calm we not only increase our ability to overcome difficulties but we also become a beacon of strength and hope to others helping them find their way to safety and resilience and if we sometimes don't feel like practicing if we sometimes don't feel or need the push it's useful to remind ourselves that we're not just doing this for ourselves we're doing this for clel Basham K Israel I'm doing this in the service of others and what I'd like to share here during this current time period of really widespread difficult emotions is how to face what we're experiencing in a Mindful and compassionate way and this is all on the level of aspirational goals we're all in this together and what's coming up for me to just name it is the grief the anger all the emotions that Dr fredman mentioned and there's a rawness but similarly to what Dr Freeman mentioned there's also the positivity that's emerged and the unity that's emerged and the possibility that's emerged and like Dr fredman said we will wake up our hearts in a collective way during this time when we're in hyperdrive that hyperarousal state that Dr Freedman mentioned with worry and all the challenges what ends up happening is fear and the difficult powerful emotions end up causing a tremendous amount of suffering and during this eight Sara it could feel contagious so what is it for us to do on a practical level even if you're not familiar with the teachings of reab nman of brv we're all familiar with his words of encouragement says know that a person has to cross a very narrow bridge and that's we're all on that very narrow bridge and rabman adjures us he reminds us and he says the main thing is to not be afraid it's a beautiful sentiment the notion that a person shouldn't feel fear at this time is absurd and unrealistic in times of pain and uncertainty fear is a natural and human response so rabi Nan's teachings can't be about suppressing our human emotions instead what reab nakan is teaching us he's navigating how we can appropriately respond to these painful emotions reab nman is precise in his wording while the popular known version of the song is shal CL that he should never be afraid reaban writes shal CL the Hebrew verb is reflexive it literally means he shouldn't make himself your at all a reflexive verb is used when you want to express that you're doing something to yourself or or sorry a reflexive verb is used when you want to express that you're doing something to yourself not that something is being done to you or that it's just happening to you in this context it's not about something happening to the person but about what they are doing to themselves re's choice of words shal underscores the idea that we have a degree of control over our fears by we relate to these difficult emotions highlighting the agency we have in our emotional responses especially in moments of intense emotion we could worry about being overwhelmed losing ourselves just drowning in it all so to some extent our Primal survival instincts are fight or flight to just disconnect from the raw emotional turmoil that we are all experiencing right now we bury or numb our emotions and get lost in our thoughts but by retreating from these difficult and sometimes painful feelings we also distance ourselves from the gift of living with full Presence at times our reluctance to embrace these difficult emotions could lead to depression chronic anxiety irritability causing tension in our muscles and our posture right now my lower back is throbbing these unprocessed emot can materialize as sensations of isolation inner restlessness monotony frequently as Dr Freeman highlighted they could manifest as addictive behaviors regardless of how these emotional states manifest when we resist them it could lead to states of unconsciousness the emotions that we end up avoiding experiencing stealthily influences our beliefs our choices and our behaviors and they become invisible forces that con strain Our Lives we and our loved ones are all in this together but by opening to the emotional experience of these difficult emotions allows us to access our natural state of resourcefulness we just begun saying and Through This Acronym of Reign of recognizing of allowing or accepting and then investigating and then subsequently nurturing we can awaken an embodied mindful presence in all inclusive heart and here's a teaching that I learned from my teachers Jack cornfield Tara Brock and Duncan Trussell and what we're going to be doing by recognizing and allowing these emotions to be there and then what we're going to do is deepen our presence that heartfelt presence in a way that can reduce fear's power with practice we discover that when we are no longer resisting these emotions we may still feel we may still feel the fear the fear is there but we stay connected to a larger space of compassion and presence and then just a gentle reminder this is just one tool of many there are many others like grounding or anchoring yourself breathing mindful walking exercise is so key social connection really trusting your own inner resources also what's become clear from Clinical Research is that when trauma and strong fear are present it's not useful to directly be open to them it's important to first soothe and calm yourself and bring in a sense of safety and love and protection also if at any point during this meditation it feels too intense I invite you to Simply open your eyes and stop the practice if you're feeling overwhelmed all right so here we go and I invite you all out there to do this with me so sitting in a posture that embodies dignity whatever that means to you and taking a few full deep breaths and you might scan and sense whatever might be going on in your life right now any of the more poignant difficult emotions that come to the Forefront and again I want to reiterate this is not the time to be bringing up any sense of traumatic fear or panic but a difficult emotion something that doesn't feel too overwhelming right now and as you bring to mind whatever you're currently feeling right now experiencing right now to make it more immediate see if you can just visualize in your mind's eye whatever it is it could be involving another person maybe see what's going on for that other person if it involves you just see the setting that might in your mind relate to or associate with that difficult or more compelling emotion if there's something being spoken about that elicits concern or fear or perhaps it's something you've been visualizing happening in the future and so we begin the practice of Reign the r is to Simply recognize recognizing whatever is most predominant and then perhaps mentally labeling that emotion worried anger grief tightness sadness and then just letting your attention be to allow the a of rain and that means an openhearted willingness to Simply pause with whatever is here and allow it simply allowing whatever you're feeling to be there some might have it some might find it helpful to make a soft mental note of it's here right now it's here right now let me be with it this belongs can I just be with it and just by allowing for a few moments it enables you to begin to shift to the eye of rain the investigating and you might notice what does this emotion feel like in your body can you identify where you feel that emotion it might be in the throat the chest the belly the back of your head even your lower back sometimes when you're doing the process of investigating you can ask yourself just the gentle inquiry of what am I believing in this moment about this emotion what does this emotion say about me what does this emotion say about my future and whatever comes up find out how your body is experiencing that emotion if you're believing that something bad is going to happen to you that you're going to lose something precious ious where do you experience that in your body and if you find it helpful you might want to place your hand wherever you're feeling that at your throat the chest or the belly for some of us we've become so disassociated from the sensations in our body that it could be very vague whatever we're feeling and that's okay just sense that you're inviting whatever wants to be accepted and included into this field of awareness just inviting whatever emotion has arisen to be felt fully breathing with whatever vulnerability you're contacting with interest with curiosity with compassion with gentleness what does it feel like how is this emotion living in my body right now in this moment and allowing yourself to attach to the very core of it whatever you're experiencing as you investigate fully allowing it without any defenses without any resistance without any rejection allows you to have that stability of surrender that surrendering presence of no resistance whatever you're feeling and just simply allowing there is an intimate attention as you make space for that vulnerable part of you what what do I need most right now and sense that you can listen from the most awake from the most Divine part of you that wise self what does this place most Need Is It Love is it accept acceptance is it faith is it hope and sense that your awake heart your compassionate nature Your Divine Soul can offer whatever is needed in this moment just allowing that vulnerable part of you to feel washed to feel bathed with some quality of tender presence of attention of loving kindness and if it's difficult for you to elicit that compassion from yourself imagine someone in your life who you trust who's wise who you know cares about from a spiritual figure from a loving presence just imagine and feel and sense that love and that care pouring in allow yourself to be nurtured just let the deepest intention be for that vulnerable place to be held to be bathed to be immersed in a Hava in loving kindness you could imagine a light a warmth feeling yourself bathed in this tender become aware of this quality of presence that's here and let yourself relax and open to that open tender presence and as best you can notice the difference between being identified as a fearful or agitated or worried self and the spaciousness the openness and the freedom of loving presence and just allowing yourself to rest in that peace within all the turmoil just taking a few more Deep full breaths and so here we are in the midst of this un unprecedented uncertainty and the turmoil that's going on outside and both inside and we need to remind ourselves can we be that person who rabman reminds us is walking that narrow bridge and still feeling the fear but you're feeling the intelligence of the fear and you know now how to hold it with mindfulness with compassion and with care so if you're intentional right now at this Junction of time if you're intentional and echoing what Rabbi Dr fredman said if you want to move through this and you will get through this the suffering and the difficulty that may arise inevitably can become some of your deepest resources please my beloved reveal yourself and spread upon all of us the shelter of your peace illuminate the Earth with your glory that we may rejoice and be glad with you hasten show love for the time has come and show us Grace as in the days of old thank you so much to Rabbi Dr Freeman thank you so much to am to everyone watching tonight's theme is you are not alone and we are here for each other you are here for your patients for your clients and we are here for you and it's so crucial to remember it's okay not to be okay and as cliche as I feel saying it in these trying times and these in these turbulent times the the danger that we're facing now Amel it's unprecedented in in most of our lifetimes and we this is the time where we're stepping up to to be there for each other to be there as one and we thank you the the amount the volume of not just forget people who are needing help and reaching out for help the volume of people out in the field professionals stepping up and reaching out to volunteer their services both people professionals here in Israel and abroad is is astounding and overwhelming and we thank you for that for everyone who's who's stepping up and doing what they can to help CLA to help Amell in this in this awful scary time but the bottom line the scary time we're here for each other hands in the middle team come on let's go one two three go team baby go team