An Interview with Psychologist Michele Bedard-Gilligan
Dr. Bedard-Gilligan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is an expert in the field of trauma, focusing specifically on post-traumatic stress disorders and the mechanisms of recovery.
Amelia Worley: Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us, Dr. Michele Bedard-Gilligan. Dr. Bedard-Gilligan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is an expert in the field of trauma, focusing specifically on post-traumatic stress disorders and the mechanisms of recovery. She has numerous publications on PTSD and individual responses to trauma, including one of her most recent publications on the topic “PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies,” co-authored with her close colleague and collaborator Dr. Emily Dworkin. Before we get started, Dr. Bedard-Gillian, can you please let us know a little more about yourself and what made you interested in studying trauma?
Michele Bedard-Gilligan: Sure. Thank you so much for having me. I'm so grateful and happy to be here today. Yeah, I actually got my first experience working with people who had survived traumatic events right after I was an undergraduate. So after I graduated, I worked for a bit at the VA hospital in Boston and worked with veterans returning from conflict either recently or many years ago and did some work trying to understand mechanisms of recovery and how trauma affected them and really just became very passionate about trauma recovery from both a research and clinical perspective. And so from there, pursued that path of really that being my career in terms of studying and treating clinically working with and individuals who've been exposed to trauma.
And so, I'm a Clinical Psychologist by training. I, like you said, I'm faculty at the University of Washington School of Medicine in the Psychiatry Department. I have a clinical practice where I see patients for a variety of reasons, including reactions following traumatic events. And then I have an Active Research Program. So, I'm the co-director of the Trauma Recovery Innovations Program at the UW School of Medicine and the associate director of the UW Center for Anxiety and Traumatic Stress, which is affiliated with the Department of Psychology.
Amelia Worley: That's great. So to begin, would you mind defining what trauma is?
Michele Bedard-Gilligan: Yeah. It's a great question. Trauma is something that actually means something very specific in the mental health field. So in the field of the study of mental health disorders, when we talk about trauma, we actually talk about something very specific. So, we define trauma exposure as being exposed to an event that either causes injury or threatens injury or threat of death or is a threat to personal integrity or physical integrity. So that is meant to characterize events where maybe there was no injury or maybe not even threat to life but they were characterized by violation of one's physical being, if you will. So, things like sexual violence fall into that category. And those types of events that meet that bar or threats of injury or threats of violence have to be either experienced directly by the individual, witnessed -So you watch it happen to somebody else, or something that you're confronted with. So, you learn about it happening to someone you really care about or someone you love or someone you're close to.
And then finally, exposure to being confronted by a lot of violence or really negative outcomes or negative harms to other people if it's in the line of work. So, this is things like emergency personnel or people who work in combat zones or war zones who are exposed repeatedly to really terrible things that happen to others that they don't know. They don't know those people personally, but they're just constantly exposed to it because of their occupation. That is also concluded in our definition of trauma. And so really specific actually in terms of how the mental health field defines traumatic events or trauma exposure.
Amelia Worley: How does trauma relate to post-traumatic stress disorder? Are some traumatic experiences more likely to develop into PTSD?
Michele Bedard-Gilligan: Yeah, that's a really great question too. So post-traumatic stress disorder is one set of symptoms, one diagnosis that can develop following trauma exposure. But I also want to be clear that following exposure to the kind of events that I just described, it can lead to a host of negative outcomes. So, we can see people develop mood problems or anxiety problems, which I know is your specialty. We can see people develop substance use problems or thoughts about suicide that they didn't have before. So, it can lead to a host of negative outcomes.
The post-traumatic stress disorder, PTSD, is one of those and it's a specific set of symptoms that really involve the traumatic events specifically. So, it's a set of symptoms where the individual re-experiences the event in terms of having nightmares or intrusive images or really strong cued reactions to things that remind them of the traumatic event. It involves avoidance of things that remind them and things that are objectively faced. But because of their association with the traumatic event, the person goes out of their way to really avoid them, which can really narrow life and cause a lot of impairment.
PTSD also involves mood and thinking disruptions. So, if we see things like anger or lots of pervasive sadness or guilt. We see things disconnecting or isolating from others, as well as really impacted belief structures, negative beliefs about oneself, negative beliefs about the world. Sometimes people take on responsibility for the event that isn't necessarily accurate, but how they view it in terms of holding themselves responsible or accountable for what happened to them. And then we see lots of hypervigilance and hyperarousal type symptoms in PTSD. So, this is on-edge, difficulty sleeping, feeling very easily startled, and very hyperalert about your environment. Those kinds of things. And so PTSD really refers to that specific symptom constellation of having symptoms in all of those categories that I just mentioned.
And following traumatic events, we see PTSD develop in what I would call a substantial minority. So, if we look across the spectrum of people who in their lifetime meet diagnosis for PTSD, it's around seven to ten percent, something like that. So, it's not most people who experience trauma exposure actually, but it's still enough and it's a substantial minority of people who will go on to suffer in this way from these specific types of symptoms.
And yes, some events are more likely to lead to PTSD than others. So we see events that are characterized by interpersonal violence in particular having higher rates of PTSD develop. So you can think about my definition of trauma exposure per the mental health field, and that encompasses the huge range of events, from natural disasters, to motor vehicle accidents, to the whole host of things life-threatening illnesses that come on very suddenly. And then it also includes things like violence that's perpetrated by someone you know or by a stranger, sexual violence, childhood abuse, so things that happen early in childhood that fall into the physical abuse or sexual abuse category. It's a huge range of traumatic events and some of those, particularly the ones that are characterized by being interpersonal in nature are more likely to lead to PTSD diagnosis than some other types of events.
Amelia Worley: Do you often see substance use overlap with PTSD?
Michele Bedard-Gilligan: Yeah, so we do. We see PTSD as something that is commonly comorbid with a variety of things. So we see very high overlap in PTSD and depression, for example. We see overlap in PTSD and other types of anxiety disorders, like experiencing panic attacks. But one place where we particularly see overlap is with substance use.
So this is true for both people who identify as male and people who identify as female. But it's actually a little more common in people who identify as female, where we see rates of maladaptive or unhelpful substance use be increased. So, people with trauma exposure and then people with trauma exposure and PTSD, specifically, will show higher rates of using substances in a way that is problematic, in a way that is getting in their way in some way shape or form. And often we think of that as sort of likely attempts to cope with some of the distress and the symptoms that develop. So substance use can be a way to either deal with negative emotions or to try to cope with those negative emotions. But unfortunately over time, what can happen is that it can then escalate in this way that it can cause problems to the individual. So we see elevated rates there for sure, yeah.
Amelia Worley: So in your experience, what is the most effective treatment for PTSD?
Michele Bedard-Gilligan: Yeah, that's a great question, and fortunately we do have really good treatments for PTSD. So I think for a very long time there was a myth that PTSD was something that couldn't be treated. After being exposed to traumatic events and developing distress related to those, that was a burden that would be there for an individual's lifetime. And fortunately, we actually know that, that's not true.
Just like any other mental health disorder, we don't have treatments that work for everybody all of the time in all circumstances, but we do have treatments that we would call pretty effective. So we have medication options. Which is not what I do, because I'm a Clinical Psychologist. But we do have medication options. So medications such as SSRIs are often used and they have effects sizes of about 0.5 and response rates of about 50%, it's about that ballpark. So a number of people who are prescribed to those medications will get a lot of relief from taking them for their PTSD symptoms.
There's also a lot of alternative therapeutics that are being investigated right now, which I won't go into too much because it's not my area really. But things like cannabis, which I do a little bit of work on. But then also things like MDMA-assisted therapy and ketamine-assisted therapies that are being looked at for helping with PTSD. Early stages, but there might be some initial promise there. But really when we think about treatment for PTSD, a lot of where it's at is in therapy approaches. So a lot of where we can be really effective has been therapy behavior change treatments for PTSD. And there's a number of them out there, so there's a number of different approaches and they have a lot of overlap with how we might approach anxiety disorders more generally.
So, for example, a lot of the treatments that we do have a sizable exposure component. So this is about helping the individual approach the reminders of the traumatic event that are causing a lot of fear, a lot of anxiety, those re-experiencing and hypervigilant symptoms that I talked about earlier. So really decreasing their avoided symptoms by using these exposure approaches. So it's involving going out into the real world and doing things that are reminiscent of the trauma but actually safe. So for an example, someone who's in a motor vehicle accident who has developed a fear of driving, and most of the time driving is actually a safe activity. And so helping the person gradually expose themselves to driving again is often a key component of treating trauma reactions.
In addition, in that same exposure realm, we think of PTSD as being a disorder that is also characterized by the memory itself and the memory taking on a very dangerous quality. So when individuals think about the traumatic event, it triggers a lot of anxiety and guilt and distress more generally. And so the exposure really involves helping individuals reprocess that memory. So go back to that memory and approach it in a way where they can sit with it, they can feel some of those emotions that that brings up. But also have that experience of gaining new perspectives and new meaning about the memory to really being able to shift their relationship with that memory, shift their relationship with the way it's impacted, the way they see themselves in the world, and also sit with those emotions so they can start to feel some decrease in them. So, it's really about processing through that memory in a way that helps them make sense and meaning out of something that, quite frankly, is quite senseless, as trauma is. And so really helping them figure out ways that they can see it and find ways to see it, so that they can gain some new perspectives and move forward. And also, correct any beliefs that might have developed that are really triggering a lot of emotion that may be not 100% accurate. So, we talked a little bit earlier about taking responsibility for traumatic events when in fact they were not your fault. And so doing exposure to the memory can help people see the places where, although they've been carrying this burden of guilt or carrying this burden of blaming themselves, and in reality that's not actually true. And so going back and going through that memory can help people shift there.
In addition, a lot of the trauma treatments that we do, so the empirically supported therapies for post-traumatic stress disorder also involve more general cognitive approaches. So, helping people identify the ways that the traumatic event has impacted their view of themselves in the world. Like how has it impacted how they think about things and learning concrete skills for being able to take those beliefs and when they're not accurate, be able to shift them to be more balanced. And so for an example there, we might have people who after a traumatic event have developed very strong beliefs that the world is just always dangerous. It's just a dangerous place. And there's a kernel of truth to that maybe. Bad things do happen and the world can be dangerous, and people who've survived traumatic events know that better than anybody. And the world is probably not 100% dangerous 100% of the time. And so helping people learn the skills to be able to see the places, “where am I safer” or “where are things more dangerous.” Being able to see that nuance again, because after traumatic events that can be really challenging and so helping them learn skills in that area.
And then finally, most of our ... all our treatments for post-traumatic stress disorder really involve a high degree of validation and support. So, following traumatic events, it's just hard. It's challenging to connect to people. It's hard to feel safe anywhere. And so really these events enable people a safe place and a safe space and hopefully a really strong, supportive environment in which to approach all this stuff. To approach their beliefs and approach their memories and approach the things in the environment that scare them and to do it in a way that's supported and gradual and systematic, and we can really make strong gains with those approaches. Yeah.
Amelia Worley: So, in the publication I mentioned earlier, PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies. You talk about how it is common for PTSD to develop following a sexual assault. Additionally, the first three months post-assault may be a critical period for natural recovery. Can you explain that idea of a critical period for recovery a little more?
Michele Bedard-Gilligan: Yeah, absolutely. So, as I mentioned earlier, when we think about PTSD and the development of PTSD, it is a substantial minority of people who develop and so it's not everybody. But immediately after a traumatic event, particularly a really severe traumatic event, we will see symptoms of PTSD, symptoms of distress in almost everybody. So, the normative reaction to something really traumatic and terrible and horrible happening is these symptoms of re-experiencing it and having nightmares about it and wanting to avoid and all of those things. But for many people, fortunately those things will go down on their own with time, and we often call that natural recovery, this idea, and what we mean by that it's just recovery that happens without intervention. It just innately or inherently occurs for the person.
And what we mean by this period, this critical period, is that what we've seen from the data and what we observe clinically is that when that natural recovery, that recovery without intervention, that organic recovery happens, it usually happens within those first three months. So those first three months, those first 12 weeks or so. I mean, obviously it's an estimate. But around that time, is really crucial for whatever learning and whatever meanings going to happen for the person innately and organically, it usually occurs in that time. And probably a lot of what that is, is people who in that aftermath of traumatic events are getting that support and that validation that I talked about or they're getting that encouragement to talk through what happened and to really confront the emotions that it's bringing up. And they're doing that on their own naturally. And so, we see this decrease in symptoms that will occur. And again, it occurs for quite a few people or quite a big chunk of people exposed to trauma. And then it seems that as the months go on, if that process hasn't happened in that natural way, then we often see people get stuck with the symptoms that they've developed and so we see those symptoms persist.
In the article you're talking about, the percentage of people who had PTSD symptoms following sexual assault one month after was quite high. It was a very large majority. And then when we followed them or we looked at the studies that have been done and we looked over time at them, we find by a year out it's less, it's slightly less than half who still have the symptoms. And that's actually high. So, for sexual assault to look and see that in a year out, almost half of the individual studied had symptoms that still met criteria for PTSD is pretty high. When we look at other types of traumatic events, we definitely see it being lower. It's lower than that. And so sexual assault and that interpersonal violence is definitely one where we see less of the natural recovery.
Amelia Worley: So digging into that further, I know you talked a little bit about the positive way that the environment can help with the recovery during those first three months. What are some environmental factors that may be harmful to the individuals' recovery during those first three months?
Michele Bedard-Gilligan: Yeah, yeah. It's a great question, what keeps those people at risk. So, we see some of the resilience surround where people are able to recover on their own comes from some of the things I talked about. And some of the risk probably comes from the inverse of those.
So people who for whatever reason aren't able to not avoid, they're not able to go back and engage in their world, either because it feels intolerable or because they're not given the opportunity. So they stay isolated or they stay, are really avoidant of things that trigger trauma thoughts or trauma memories. People who don't have natural avenues for support, either because they don't exist, social support is what I mean, either because they don't exist or because they're not able to take advantage of them or because they are experiencing so much avoidance, there's so much distress that they don't reach out or they don't share or they don't talk about it. Or because sometimes what people, sometimes even well-intentioned, reactions we might get in our natural social support environments just aren't helpful.
And again, this is in our culture pervasive. Something really bad happens, you reach out for support in your natural environment and some of what you might get back is, "Just don't think about it. Just try not to think about it." But that's actually the opposite of what we think is helpful. And it's well-intentioned and I see where people come from when they give that kind of feedback and it can also really backfire. If we think what we need is actually to process and to feel the emotions and to really engage with the experience and the memory in order to make sense of it and move forward, not talking about it is the opposite of that.
And then of course there are also extremes. So, we know from the research that's been done that, unfortunately, a sizable number of people when they disclose traumatic events will get what we would call negative reactions. So, they will get either somebody blaming them for what happened or telling them that it was their fault or telling them that they should have done something different or telling them that if they were stronger, they would've just moved on from it. Those kinds of things that we know are actually incredibly harmful. So, for people who get those reactions, they're at much greater risk for developing long-term symptoms.
And then finally, substance use and the overlap of substance use with PTSD is something I care passionately about and something that I do a lot of work on. And we also know that substance use in the immediate aftermath of a traumatic event can keep people stuck as well. So, when people are using substances maybe to cope or for other reasons, it can prevent that processing and prevent that adaptive coping and can unfortunately cause more negative outcomes as well.
Amelia Worley: That's really interesting. I noticed that you have many research projects working with young adults. What are some differences in the way adolescents and young adults process traumatic experiences compared to older adults?
Michele Bedard-Gilligan: Yeah, it's an interesting thing to think about, about how age and developmental period impacts how we might make senses of the really difficult things in life and how we might cope or find resources following traumatic events. In general, age has not been found to be a very robust predictor of who's likely to develop PTSD. So it's not something where we think about as a background characteristic that's really going to impact whether or not someone goes on to develop distress. That being said, I do think there are some things that we know about what is important to pay attention to. So younger people in general are more likely to be exposed to traumatic events and so there's just a slightly higher risk there. So, in terms of being exposed to trauma, which then obviously puts you at risk for developing post-traumatic stress disorder.
In addition, I think depending on developmental period that younger individuals sometimes have less access to resources, less access to outlets for support. They may be living in environments that are perpetuating the traumatic events or trauma exposure, and not have a whole lot of control on how to get out of those environments. Just because, generally speaking at younger developmental ages, we often have less agency over our environments and in what's going on around us than we do as adults.
So that could be a difference. As well as depending on how young an individual is, what cognitive and emotional resources they have to make sense of things, that can be challenging as well. And so those are some of the main differences, whereas ... Yeah, I think I would just stop there. Those are some of the main differences, I think in terms of how we think about how different age categories might respond to traumatic events differently.
I think your observation that a lot of the work that I do is with younger adults really reflects that first point. That when we are doing studies or where we're intervening and promoting trauma recovery with various therapeutic approaches and we're looking to the community for people to come in and participate in our study and help us learn about these therapies we often see a bias towards individuals who are younger wanting to do those things and or having more of a need for it.
So when you do a research study, for example, where we're providing treatment free of cost. This is really helpful to individuals who may fall into a bracket where they don't have health insurance or the health insurance plans their parents and they don't really want their parents to know that they're doing this. So something along those lines. And so, I think some of it is also a resource thing as well as a need and a vulnerability thing. Yeah.
Amelia Worley: Lastly, do you have any advice or anything you want to share with our listeners suffering from exposure to trauma or PTSD?
Michele Bedard-Gilligan: Yeah. I think hopefully some of the things I've talked about in terms of what it looks like and the treatments that are out there for it is helpful to people in terms of if they're looking for options and they are feeling like they need help. I think the couple of things that I would really want to drive home I guess.
One, being that trauma exposure is actually incredibly common. So, when we do big national surveys, it's anywhere, it's over 75% of Americans who've experienced, or people living in the U.S., who have experienced at least one traumatic event by our definition. So, this is an incredibly common thing and so experiencing trauma, it's not unusual and it doesn't make you an outlier in any way actually. And then that it does lead, we know that it leads to all kinds of increases in distress and makes people vulnerable for all outcomes. It's not a guarantee. Many people are very resilient, and like I said, many people can use the resources and the things they have around them in order to not develop things, distress that is impairing. But many people do and it's not abnormal and it's not something to feel ashamed of. It's not about strength, it's not about being weak, it's not about any of that. It's just about the real effects that these really kinds of horrific experiences have on us as human beings. And because we know this, because we know it can have these predictable effects, I think anything we can do within our communities, within ourselves, within the people close to us to decrease stigma around it. To decrease this idea that experiencing trauma is something that we should be ashamed of or something that leaves us to be marked for life or any of that, is something that I really hope we can start to move past and instead really think about it as something that shapes us as people.
And when it causes distress that's impairing, when it causes symptoms or problems that are getting in the way of us functioning or leading the lives we want to live, that there are things we can do about that. And there're treatments out there that are helpful, that we can start by just reaching out for support if we have people in our lives who can provide that. But when that's not enough, there's other more professional, higher level care options as well. Yeah, and so I think those are just some of the things that I would hope people would be able to hear and understand and that hopefully would be helpful.
Amelia Worley: That's great. Well, thank you so much, Dr. Bedard-Gilligan. It was wonderful having you on our series today.
Michele Bedard-Gilligan: Thank you. I appreciate it.
For more information, click here to access an interview with Psychologist Robyn Walser on trauma & addiction.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.