Overcoming Traumatic Stress
- What is Trauma?
- In a traumatic experience the normal capacity to cope is completely overcome by a terrible event the person may have experienced or witnessed, that involved serious injury, threatened or actual death. The person may have feared they would suffer physical harm and been overwhelmed with fear.
- Occasionally the after-effects of a trauma may be more traumatic than the initial trauma e.g. serious injuries may have occurred.
- Traumatic events are of three types:
- man-made disasters e.g. fires and transport disasters;
- natural disasters e.g. floods and earthquakes;
- acts of violence, crime and terrorism e.g. domestic violence, rape, bomb explosions.
- Some people may experience various life events as traumatic e.g. redundancy, divorce, bereavement.
- Vicarious traumatization occurs from working with trauma survivors in a caring and empathic way.
- Reactions After Trauma
- To learn to cope you need to examine the traumatic experience and understand your reactions and the distressing responses produced since the event. You need to confront any deeply buried memories, thoughts and feelings connected to the trauma, which may be preventing you from moving forward.
- As you start to gain control again the trauma will loosen its hold.
- While working through this advice should you feel distressed please try to distract yourself with a different activity.
- There are three main symptom groups for the reactions following trauma - (DSM IV):
- Re-experiencing the event (Intrusive reactions) – A feeling that you are experiencing the original event all over again, through memories intruding into your waking or sleeping life.
- Arousal reactions – You feel persistently aroused in a nervous, agitated sense, anxious, tense, unable to settle or concentrate, over-reacting very sharply to small things and especially, have trouble sleeping.
- Avoidance reactions – You make frantic efforts to avoid anything that could remind you of the trauma, or cause you to think or talk about it in any way. You may shut down your feelings about other people and things you normally care about and keep to yourself. You may feel unusually withdrawn and emotionally numb.
- In most people the above responses subside after a few days or weeks following the traumatic incident. If instead they recur over and over again you may be suffering from Post-Traumatic Stress Disorder (PTSD) and need to consult your doctor for a diagnosis.
- In PTSD arousal reactions are due to the fight/flight stress response failing to shut off so that the system is stuck on red alert that the environment is dangerous so the traumatized individual is prone to over-reacting to everything.
- Post-trauma sufferers may come to dread socializing due to the embarrassment caused by their unusual responses. They also go to great lengths to avoid anything that reminds them of the trauma e.g. watching the news or reading newspapers.
- All these responses interact with each other to keep a vicious cycle going:
- Re-experiencing the event (Intrusive reactions):
Flashbacks are memories through which you experience the original event as if it were happening all over again. They can occur during waking hours or when asleep in dreams or nightmares.
Intrusive recollections – Most people will find they continually recollect the traumatic event although not every vivid detail is experienced as a flashback. Your security of the world before trauma has been violated and almost anything can trigger traumatic associations in an instant. - Arousal Reactions:
Sleep disturbance is the most common after-effect of trauma.
Bad temper, lack of concentration, hyper-alertness and exaggerated concern for safety, exaggerated startle response and panic attacks are all arousal reactions. - Avoidance Reactions:
Avoidance behaviour – You avoid any person, place or thing that reminds you of the trauma.
Emotional numbness – this is a form of avoidance behaviour where your capacity for experiencing feelings is shut down.
- Re-experiencing the event (Intrusive reactions):
- You may experience difficulty in communicating with others, feel disconnected from your surroundings and your ability to cope with intimacy is affected e.g. unexpected physical contact may make you jump.
- Alcohol, drugs and comfort eating may be resorted to but such behaviours can only temporarily improve things.
- Depression may be associated with traumatic grief. You need to seek help from your doctor if you think you are suffering from depression.
- Guilt and self-blame are common and decreased self-esteem and loss of confidence.
- Reactions of Others Close to You
- Many family members and loved ones find it difficult to cope with the change from the emotional scars of the trauma, in the trauma victim. They may try to help but the recipients do not readily accept this help and it may not have any effect.
- It is not that the trauma victims stop loving others as before the trauma but that their normal response to people has been incapacitated, for the present.
- In a well-functioning relationship there is openness and good communication. Trauma survivors find opening up difficult - this may be due to feelings like shame that they are losing control or because it is stirs disturbing memories and emotions. They need to be encouraged to share their internal distress and experiences with others.
- Healthy relationships need trust and trauma can shatter a person’s capacity to trust.
- There is a need for fun, recreation and relaxation in relationships and trauma victims lose interest in previously enjoyed activities.
- Allow the traumatized person to heal in their own time – do not pressurize them to get better.
- Recognize that trauma affects each individual differently.
- Without pressurizing them, make the trauma victim aware that you are available to listen to them if they feel like recounting their story.
- When the traumatized person tells their story they are likely to experience strong emotions and these need to be expressed as part of the normal healing process.
- Try to give the trauma victim a sense of stability and routine at this time. Major life decisions should be postponed for at least six months.
- It is important to treat each other as equals.
- Write down what changes you would like to make to your relationship and how you are going to work together to achieve these goals.
- Support for partners is available from professional agencies or you might confide in someone outside the family.
- If your partner’s reactions are overwhelming you should protect yourself and withdraw.
- The Path to Recovery
- In a note book keep a record of your progress towards recovery and date all the entries.
- Allow yourself time to work through this advice and also time for recreation and relaxation.
- Be responsible for your own safety and control destructive impulses e.g. suicidal thoughts – seeking professional help if they persist.
- Do not abuse alcohol or drugs or keep anything potentially dangerous in the house.
- Make a contract with yourself by:
- Considering the obstacles to your recovery, both external obstacles e.g. not enough time in the day, and internal obstacles e.g. fear of change.
- Writing down desired changes to remove as many of these obstacles as possible and how and when you intend to make these changes.
- Making a list of things you promise yourself to do that will help in your recovery process e.g. ‘I will persevere in my efforts and reward myself for every success no matter how small’.
- You may have felt that others did not want to know about how the trauma affected you emotionally – that they were only concerned with the physical aspects; you may have found it too distressing to share your experience of trauma; you may have been ignored because your injuries were not as serious as that of other people; you may have been blamed for the trauma and no one was sympathetic to how the trauma affected you.
- To understand the trauma you need to clarify what exactly occurred, your reactions to it and what it means to you.
- You may be able to talk about your experience of trauma to a friend you trust. Your feelings may get overwhelming so make sure you keep yourself safe.
- You could try writing about your trauma to understand your experience: do this only if your trauma is actually over; spend a set regular time daily on this exercise then do a pleasurable activity afterwards; give yourself as much time as you need to write a detailed account of your experience in the present tense using the first person e.g. ‘I feel..’; allow yourself to acknowledge any feelings that may arise.
- If at any time you feel overwhelmed, distract yourself – if your distress continues seek professional help.
- If writing is difficult you could follow the same procedure by dictating your experience on tape. Painting, drawing, making a collage or sculpture or writing a poem or song to express your experience are also alternatives.
- When you have completed this exercise remember to reward yourself.
- Dealing With Your Intrusive Reactions (1)
- You need to familiarize yourself with your intrusive reactions so you have a baseline to measure your reactions before you start to make any changes. In this way: after making changes another measure will tell if the changes you have made lessen your reactions; you will be able to see your progress as the difference between the baseline and subsequent scores; you will know when certain strategies are not working and should seek professional help.
- In your notebook, for each of the following questions rate:
- Rate how frequently you have had each of the experiences over the past week using the scale 0 (not at all), 6 (almost always).
- How upsetting each of the experiences has been in the past week using the scale 0 (not at all upsetting), 6 (extremely upsetting).
- In the past week have you had intrusive thoughts, images, sounds or smells in your mind about your traumatic experience?
- Have you been disturbed by dreams or nightmares about your traumatic experience in the past week?
- In the past week have you had flashbacks that the trauma is happening all over again?
- In the past week have you felt emotional when you remember your traumatic experience?
- In the past week have you felt physical discomfort when you remember your traumatic experience?
- Record the total for frequency and the total score for upset by adding the score for each of the questions for the two categories. If your score is 10 or below, it is low; 10-20, it is mid-range and 20 or more, it is high
- Also rate how disabling these intrusive reactions have been in the past week using the scale 0 (not at all disabling), 10 (severely disabling).
- If your scores have been high, professional help may be useful in addition to this advice.
- Dealing With Your Intrusive Reactions (2)
- Dealing with intrusive memories:
- From the following exercise you will find out how often you push intrusive memories away.
- In your notebook record the date and make a table with columns for: time; intrusive memory; bodily sensations; level of distress 0 (no distress), 10 (severe distress); tolerable; dismissed it.
- Then note the time and for one hour continue with your activities as normal. In this time observe if any intrusive memories enter your mind and note each one in the table rating your level of distress. Record also how you coped with the memory by ticking one of the last two columns.
- Stop after an hour and check how often you tried to push your intrusive memories away. Be aware of the bodily sensations you experience and the level of distress at which you find the intrusions intolerable.
- The next exercise will help you to integrate the intrusive memories into your life.
- You will need to allocate half an hour a day on a regular basis for this exercise.
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- In your notebook record at what level of distress you found the intrusions intolerable and what physical sensations did you notice?
- Try to make yourself feel the bodily sensations you experience at that level of distress. Stay relaxed and aware as long as you can of these sensations you experience when intolerably distressed.
- It may help to give your bodily sensations a shape or colour and explore changing its form or colour.
- By allowing yourself to experience your bodily feelings you will realize that tolerating them is feasible.
- Repeat this exercise for a week until you can tolerate your bodily feelings at that level of distress then repeat the exercise for finding out how often you push intrusive memories away, to measure the strength of your distress.
- When you no longer need to dismiss the intrusions that result in that level of distress try the exercise to expose yourself to your bodily sensations, moving to the next higher level of distress.
- Dealing With Your Intrusive Reactions (3)
- Dealing with flashbacks:
- First you need to understand what occurs when you have a flashback.
- Answer the following questions in your note book and record any observations:
- Recognizing the triggers: when, at what time, in what circumstances and were you alone or with others when it happened?; what are the similarities between your present situation with that of your flashback?; can you recollect feeling this way before and what are the similarities and differences?; what do you think triggered it e.g. thoughts, smells, media?
- Recognizing the traumatic memory: can you recall your flashback? Write it down or draw it in as much detail as possible; what was the duration of the flashback?; were you conscious of your external environment?
- Becoming aware of your bodily sensations: Note the sensations you experienced during the flashback in as much detail as possible; what was your level of distress at these sensations – 0 (no distress), 10 (severe distress); what were your thought and reactions to these sensations?; how did you make yourself feel better this time and in the past?
- Flashbacks occur because your mind is trying to make sense of what happened.
- There are three stages:
- The trigger stage which tells you the initial cause of the flashback.
- Upsetting memories make you feel as if the trauma is happening all over again.
- Experiencing strong physical sensations.
- Identify and record your most common triggers for your flashbacks.
- Monitor your flashbacks over a long period of time to gain understanding of them.
- Draw a table with columns for: date/time; trigger; flashback (content); your reactions; level of distress 0 (no distress), 10 (severe distress); how long did the flashback last?
- After you can identify a flashback and are aware of your reactions you can try to control your flashbacks.
- You can control flashbacks by avoiding known triggers to your flashbacks. This can be useful if you are experiencing very strong reactions that may be a danger to others.
- Go through the common triggers you identified earlier and your flashback monitoring record to mark out the triggers it would be helpful to avoid.
- Make a list of triggers to avoid and a plan of how you will avoid each trigger.
- Using your notes on common triggers and your flashback monitoring record categorize your triggers into for groups:
- Triggers you feel you could deal with now;
- Triggers you feel you could deal with soon;
- Triggers you feel you cannot deal with now or soon but hopefully eventually;
- Triggers you feel you will always need to avoid for everyone’s safety.
- Now choose a trigger you feel you can deal with now and try the following strategies.
- Write down in detail the flashback associated with this trigger. In what ways does the flashback cause you distress and why does this have such an effect on you? What feelings do you experience when you have the flashback? Now using these notes:
- Rescript the flashback:
- Consider if there is anything in the imagery of the flashback that you could alter to gain more control over the flashback.
- Rewrite the flashback with this altered image. Visualize the flashback in this altered form.
- Every time this trigger sets off this flashback you should rescript the flashback.
- Resize your flashback:
- Visualize your flashback as a film – try to fit the image onto a small television screen and practice viewing it as frequently as possible. Reduce the speed and colour and pause frames as you wish.
- Every time this trigger sets off this flashback you should watch it in the above manner.
- When you feel you can tolerate this trigger you can select a different trigger to work on.
- You can use Grounding techniques to reduce the intensity of your flashback and reconnect with reality:
- When a flashback is triggered immediately focus on any object in your surroundings and describe it in detail to yourself including its use and your feelings about it.
- Grounding smell: Choose a pleasant scent that does not remind you of your trauma and carry an item that smells of this scent. As soon as flashback is triggered, breathe in this scent and be calmed by it.
- Grounding object: Carry a small object (e.g. a stone) that you can feel and study as soon as flashback is triggered.
- Grounding position: Find a bodily position which is comforting and use it as soon as a flashback is triggered.
- You could also try reciting a poem or singing a song.
- If you experience flashbacks related to sexual abuse, in a sexual relationship:
- You should stop any further sexual contact until the flashback is over and focus on your immediate surroundings as soon as the flashback is triggered and note the differences between your partner and present environment to your abuser and environment in your flashback.
- Make sure your partner is aware you are having a flashback and let your partner comfort you in ways you have discussed beforehand. Use any of the grounding techniques mentioned above.
- Re-score yourself (See Dealing With Your Intrusive Memories (1) and compare the new score with the baseline score. Remember intrusive memories and flashbacks are the body’s way of making sense of your traumatic experience. Reward yourself on your successes.
- Rescript the flashback:
- Dealing With Your Arousal Reactions (1)
- You need to familiarize yourself with your arousal reactions so you have a baseline to measure your reactions before you start to make any changes. In this way: after making changes another measure will tell if the changes you have made lessen your reactions; you will be able to see your progress as the difference between the baseline and subsequent scores; you will know when certain strategies are not working and should seek professional help.
- In your notebook, for each of the following questions rate:
- Rate how frequently you have had each of the experiences over the past week using the scale 0 (not at all), 6 (almost always).
- How upsetting each of the experiences has been in the past week using the scale 0 (not at all upsetting), 6 (extremely upsetting).
- In the past week have you suffered from sleep disturbance either initial insomnia, broken sleep or early morning wakening?
- In the past week have you been aware of being angry or irritable?
- Has your concentration been poor in the past week?
- Have you been overly cautious and preoccupied with the safety of yourself or others?
- In the past week have you felt more agitated than usual?
- Record the total for frequency and the total score for upset by adding the score for each of the questions for the two categories. If your score is 10 or below, it is low; 10-20, it is mid-range and 20 or more, it is high
- Also rate how disabling these arousal reactions have been in the past week using the scale 0 (not at all disabling), 10 (severely disabling).
- If your scores have been high, professional help may be useful in addition to this advice.
- Dealing With Your Arousal Reactions (2)
- Ensure you have secure or new locks on your doors and windows so you feel protected. You may consider moving house if the trauma occurred in your home. While you are recovering you may need to sleep alone – discuss this with your partner and reassure them that this is only temporary.
- Sleep Management:
- The length of sleep necessary varies from person to person.
- Worrying will prevent you from sleeping.
- You need less sleep as you get older.
- Sleep is affected by mood, stress, food, alcohol, exercise and medicines.
- In the long-term, sleeping tablets are not helpful and can be addictive.
- You can manage your sleep problems by changing your behaviour rather than resorting to medication.
- Keep a sleep diary for several nights to ascertain if you have a problem. Note the date and anything that might affect your ability to sleep e.g. your activity before retiring. If you have waking episodes, note your activity to restore sleep. Was it helpful? Next day note the number of hours of sleep you managed to get and rate how alert you feel 1-10 (1 is dull and sleepy and 10 is very alert). Rate your performance that day 1-10 (1 is poor performance and 10 is performed well). If you do have a problem the following suggestions might be helpful:
- Analyze your sleep diary to see if there are behaviours which result in poor sleep that you could change?; identify helpful and unhelpful ways of coping and avoid the latter.
- Introduce pleasant smells into your sleeping environment to help you relax e.g. potpourri or lavender oil.
- Try to relax an hour or two before you go to bed. Seek counselling or the support of friends if you feel the need. Exercise during the day. Avoid caffeine, nicotine and alcohol and try a warm milk drink before bed. Make sure you are not hungry before retiring as this will keep you awake.
- Ensure you have a quiet bedroom and a comfortable bed and have emptied your bladder before trying to sleep. Use your bed only for sleeping and set an alarm so you wake regularly each day. Avoid naps during the day.
- If you sleepwalk you are advised to discuss this with your doctor as it can be dangerous.
- To cope with disturbing dreams you could try:
- Constructing a positive ending to your disturbing dream and mentally practicing this alternative ending several times before sleeping.
- Practicing beforehand what you might say if the dream occurs.
- Keep water and a towel by your bedside to wash your face with if you wake up sweating – this will help you re-orientate.
- Keep a notepad and pencil within reach so you can record your dreams but beware of reading too much into their interpretation.
- Relaxed Breathing Method:
- You could try the following method of relaxed breathing to ease tension and promote sleep:
- Ensure you have some time to yourself and push your worries to one side.
- Sit or lie comfortably and close your eyes with your arms by your side.
- Concentrate on breathing naturally.
- Place your hands on your stomach and breathe in deeply and hold for a few seconds feeling your stomach rise. Breathe out and feel your stomach contract. Repeat and as you breathe out think of a relaxing image or sound. Continue doing this until you feel thoroughly relaxed.
- Count back from 10 then open your eyes and feel how relaxed you are now. Slowly get up and resume normal activities.
- Dealing With Your Arousal Reactions (3)
- Managing Your Anger:
- You need to learn to deal with your anger effectively rather than suppressing it or being enraged.
- Keep notes about your anger – when and why you are angry; your thoughts and behaviour when angry; rate how strong your anger is using the scale 0-10, 0 (irritated), 10 (enraged).
Make honest, daily anger notes for a fortnight or more, dating each entry – this will enable you to see what things need to be improved.
Answer the following questions in your notebook:- How frequently do I get angry?
- Do others know when I am angry?
- Does my anger help me to cope?
- Is my anger preventing recovery?
- What do I achieve from being angry?
- Can I obtain these things in other ways?
- Do I express anger in ways others expressed anger in my childhood or differently?
- How do the ways I handle anger compare for before and after my trauma?
- Do I feel relief from getting angry?
- Are there alternatives to getting angry yet achieving the same sense of relief?
- Could I consider forgiveness as opposed to revenge or a compromise between the two?
- Dealing With Bodily Sensations:
- Consider the physical sensations that tell you that you are becoming angry e.g. do you become tense and sweat?
- Control your physical sensations due to anger, by using the Controlled Breathing and Relaxation techniques detailed in the next two sections.
- Specific anger management techniques:
- The ‘Time-out’ technique:
Discuss with your partner and others concerned beforehand that as part of learning to control your anger, you will take a ‘Time-out’ next time you are angry. This means that you will leave to be alone for no more or less than an hour, when you feel your anger rising. During this time you should not drink or drive. Use any technique that will help you to calm down and not over react when you return e.g. controlled breathing or physical exertion. Explain to those concerned that you are not rejecting them nor should they worry about you when you need to be alone to calm down. Request their support in your efforts at anger management. - The ‘Thermometer’ technique:
Visualize a large thermometer with red mercury to represent your temper. Allow yourself to see the graduation marks.
When you are calm there is just enough mercury for effective interaction with others. As you become agitated the temperature will rise – you will be aware of bodily sensations such as quickened breathing and flaring nostrils.
All thermometers have marks at the top for a ‘danger zone’ and you need to bring the mercury down before you get into this zone where you will lose control over your thinking so will be unable to act appropriately.
Use controlled breathing or the ‘time-out’ technique or any other means to get the mercury to fall to a safe level where you are in control of your anger.
When you reach room temperature level you can deal with the situation in a rational manner.
You will need to use this technique regularly for effective results. - The ‘Assertive Communication’ technique:
Clarify what you want to discuss that is upsetting you.
Communicate your feelings using ‘I’ statements e.g. ‘I am frustrated…’
Specify the action you want to happen.
State any stipulations or consequences.
Thank the other person for listening.
Try rehearsing the ‘Assertive Communication’ technique before an encounter.
- The ‘Time-out’ technique:
- Keep notes about your anger – when and why you are angry; your thoughts and behaviour when angry; rate how strong your anger is using the scale 0-10, 0 (irritated), 10 (enraged).
- If you are doing yourself physical damage e.g. cutting or self-mutilating, you are not coping and should seek the help of a professional.
- Dealing With Bodily Experiences: Controlling Your Breathing
- Hyperventilation – faster breathing occurs in response to exertion and stress. In the long-term this can be uncomfortable and cause unpleasant physical symptoms which trigger more anxiety and more hyperventilation. Another cycle of stress is set up and can result in a panic attack.
- You can rectify hyperventilation by learning to control your breathing.
- First practice lying down and later sitting or standing. Place one hand on your stomach and the other on your chest. Breathe in slowly through your nose until your lungs are full then exhale slowly through your nose. Breathing in and out counts as one breath – aim to take 8-12 breaths a minute.
- In order to be effective you need to practice this exercise repeatedly.
- Dealing With Bodily Experiences: Relaxation
- You need to develop relaxation into a skill you can use when you feel muscular tension due to stress.
- Try to develop a routine and practice your relaxation exercises. Start by lying down and later you can try sitting or standing. Control your breathing.
- Record your experiences noting the date and time. Rate your distress before the relaxation exercise, 1-10 (1 is tense and 10 is very relaxed). Which exercise did you use? Rate your distress afterwards. Make notes of the sort of day it was, your preoccupations etc.
- Below are three exercises – only move to the next one when you are fully relaxed after a routine.
- Progressive Muscular Relaxation (PMR) – Breathe slowly and regularly as you focus on different parts of the body:
- feet – tense your feet then relax and repeat;
- legs – straighten your legs then relax and repeat;
- abdomen – tense your abdomen then relax and repeat;
- back – arc your back then relax and repeat;
- shoulders/neck – bring your shoulders up and in and press your head back. Relax and repeat;
- arms – stretch out your arms and hands. Relax and repeat;
- face – tense your face and bite hard then relax and repeat;
- whole body – tense your whole body then relax and repeat.
After the routine if you still feel tense then repeat it then when you are relaxed think of something calming to relax your mind. Get up slowly and gently.
You should practice PMR twice a day until you feel relaxed after the exercise. - Shortened PMR – You can miss out the tensing and go straight to relaxing the different muscles. When you have achieved this you can progress to using the routine at other times and places.
- Simple Relaxation Routine – Identify a word, object or scene you find calming. Sit comfortably and close your eyes. Be aware of your breathing as you inhale through your nose. As you exhale, think about your calming mental image. Continue this until you feel relaxed. You should practice this exercise frequently.
- Progressive Muscular Relaxation (PMR) – Breathe slowly and regularly as you focus on different parts of the body:
- When you have learned to relax using the three exercises you can start to use the skills throughout the day. Use something to remind you regularly to relax. Apply your relaxation skills whenever you need to use them in response to physical tension.
- As well as the above techniques you could try healthy physical exertion e.g. taking a vigorous walk.
- Dealing With Your Avoidance And Emotional Numbing Reactions
- You need to familiarize yourself with your avoidance and emotional numbing reactions so you have a baseline to measure your reactions before you start to make any changes. In this way: after making changes another measure will tell if the changes you have made lessen your reactions; you will be able to see your progress as the difference between the baseline and subsequent scores; you will know when certain strategies are not working and should seek professional help.
- In your notebook, for each of the following questions rate:
- Rate how frequently you have had each of the experiences over the past week using the scale 0 (not at all), 6 (almost always).
- How upsetting each of the experiences has been in the past week using the scale 0 (not at all upsetting), 6 (extremely upsetting).
- In the past week have you tried to dismiss any thoughts or feelings connected to your traumatic experience?
- In the past week have you avoided situations, places and conversations that remind you of your traumatic experience?
- In the past week have you tried and been unable to remember anything about your traumatic experience that is of importance?
- In the past week have you not been able to enjoy yourself as much as usual?
- In the past week have you felt distant from others around you?
- In the past week have you felt emotionally numb?
- In the past week have you been indecisive and pessimistic about the future?
- Record the total for frequency and the total score for upset by adding the score for each of the questions for the two categories. If your score is 14 or below, it is low; 14-21, it is mid-range and 21 or more, it is high
- Also rate how disabling these arousal reactions have been in the past week using the scale 0 (not at all disabling), 10 (severely disabling).
- If your scores have been high, professional help may be useful in addition to this advice.
- Dealing with Avoidance:
- Panic reactions can lead to a vicious cycle where anxiety results in avoidance and the anticipation of more anxiety, hence more avoidance.
- Handle panic by reminding yourself that there is no need to be frightened and use the controlled breathing technique.
- Use coping statements e.g. ‘I can deal with this’ ‘ It will be over soon’
- Continue in the situation slowly and calmly. When you are in a suitable place try using the Relaxed Breathing Method (see Dealing With Your Arousal Reactions (2)).
- Reward yourself for your progress with this advice.
- For a fortnight keep detailed notes of the circumstances when you feel panic or anxiety.
- Make a list of things you avoid because of your panic attacks and select the easiest for graded exposure. Work through the list from the next easiest to the most difficult.
- Avoidance: Graded Exposure
- To overcome your fear you need to face it at your own pace. Identify and write down an accurate description of your fear. Deal with one fear at a time.
- Graded exposure will show you that your fears are not really alarming and build your confidence. You are trying to learn to master your anxiety rather than avoiding it. There are three stages:
- Setting targets – Your descriptions of fears such as objects and situations that cause avoidance and anxiety needs to be arranged in order of difficulty with the easiest first. These are your targets.
- Grading tasks – Choose a target and plan a series of steps which become progressively difficult so that you can build on your successes. Each step should be altered in one aspect at a time to increase the difficulty and allow you to build your confidence. E.g. If your target is to shop at the supermarket, alone – you could start by shopping for one item at the local shop with the correct money then with a credit card then buy several items with a credit card. Next you could try graded steps at a local store followed by a mini-market and finally at a supermarket.
- Practicing – Repeat each step until your anxiety is no longer there, then proceed to the next task and reward yourself for your achievements.
- Keep a diary to remind you of your progress. Note the date and task and give a rating for your anxiety 1-10 (1 is no distress and 10 is most distress). Write down any other related details.
- Dealing With Safety Behaviours:
- If your trauma occurred while driving or in a similar activity you may find yourself being extra cautious in doing these activities again. Your body remembers the danger and is trying to protect itself. You need to realize that these situations are no longer dangerous.
- List the sorts of safety behaviours you are using and deal with them one by one. You need to realize that they are not necessary and use controlled breathing and relaxation techniques to help you cope.
- Dealing With Emotional Numbness:
- You need to be able to acknowledge your traumatic experience in its entirety.
- You may feel that the trauma has prevented you from achieving your dreams or has caused the loss of your identity.
- You need to consider who you are and how you see yourself and how you compare yourself to others now, after the trauma; What do you fear others will see or are fearful of admitting to yourself?; How have your personal expectations altered since the trauma?
- Use the technique of graded exposure to deal with emotional numbness reactions.
- Numbness is often associated with grief and this will be dealt with later.
- Alcohol, drugs and comfort eating:
- The numbness reaction often extends to the overuse of alcohol, drugs or comfort foods. Anorexia nervosa can also be triggered by a traumatic experience.
- If you feel you have a dependency, contact your doctor and seek the necessary help.
- Intimacy problems:
- You may feel alienated and incapable of connecting with anyone intimately. As before use the technique of graded exposure to deal with this avoidance behaviour.
- Dealing With Interpersonal Relationships
- Interpersonal relationships may have caused your traumatic stress disorder or may be preventing you from recovering – in any event interpersonal relationships will be affected by your traumatic stress disorder.
- You need to understand your personal relationships and be able to deal with them effectively.
- Draw interpersonal maps – one for before you developed traumatic stress disorder and the other for afterwards:
- How your interpersonal relationships are at present;
- How your interpersonal relationships might be now if you did not suffer from your emotional problem;
- How your interpersonal relationships will be in 10 years if you continue to suffer from your emotional problem;
- How you would ideally like your interpersonal relationships to be.
- These will summarize all your relationships and allow you to recognize any changes you may desire.
- List all your important relationships and put yourself in the middle of the map in a circle.
- Place each person’s name in a circle on the map, around you in the middle – the closer the relationship to you, the closer the circle to you.
- Join these circle’s to you in the middle with an arrow outward if it is you mainly giving; an arrow inward if you are mainly receiving; a two-way arrow if giving and receiving is balanced; a question mark if you are unsure.
- You could also draw maps for how you would ideally like your interpersonal relationships to be; how your interpersonal relationships might be now without traumatic stress disorder; how your interpersonal relationships will be in 10 years if you still have traumatic stress disorder.
- Examine these maps noting any differences and set yourself goals to make any desired changes to your relationships.
- For each relationship ask yourself:
- who initiates and terminates contact;
- are you happy with how often you see this person? ;
- who decides what to do or what to talk about? ;
- is there a balance between giving and receiving? ;
- do you want to alter the relationship in any way?
- Consider questions such as:
- who could I confide in and get advice from? ;
- who would be there for me if I fell ill? ;
- who would lend me money at very short notice?
- Next time you have contact with each person, examine the relationship – participate and observe. Were your predictions correct? – If not, what was different?
- When you have a complete picture of your relationships, think about how you maintain them and in what way you want to change your relationships.
- Two important reasons for making changes are:
- A balanced and supportive social network is necessary for your well-being;
- By altering your relationships but avoiding being controlling, you may increase your sense of control.
- Start by making small changes and monitoring progress. You could also try discussing what you have learned about the relationship with the individual.
- Removing The Obstacles To Intimacy
- Record and examine closely the things that prevent you from achieving intimacy with someone. Note your thoughts and reactions when you distance yourself from a friend or end a relationship and make an analysis e.g. are you overgeneralising?
- Social inadequacy can be an obstacle to intimacy. Apply your assertiveness skills to your social and work life and observe how socially skilled people handle situations in particular difficult ones. Rehearse your social behaviours so that you are comfortable with them.
- Try to grasp your anxious thoughts, examine them closely and if required, challenge them. What are your anxious thoughts? Is your outlook biased – are there misjudgments? Consider the evidence to support and discount your thoughts.
- See ‘Overcoming Social Phobia’ in the Forward Counselling Advice Service.
- It is possible to become over-intimate and make ourselves vulnerable to exploitation. Trust can be given in a series of stages and you can fluctuate as to how much you trust someone.
- Communication is necessary for all relationships. Record the feelings which threaten your relationship (e.g. jealousy) and grasp the automatic thoughts. Analyze them and find alternative ways of dealing with the situation.
- Before and Beyond Your Trauma
- Before the trauma people have had to cope with negative and positive experiences. Beyond the trauma people’s experiences whether negative or positive are affected by the trauma – their energy seems to be stuck at the time of the trauma in the negative life experiences.
- Lifespan Exercise:
- This exercise will enable you to see that life has been moving on and that you have survived.
- Ensure you have at least two hours to yourself and on a large piece of paper draw a vertical line down the centre. Starting from the bottom, plot your earliest recollections and work your way to the top and where you are now. Plot negative experiences on the left and positive experiences on the right.
- If you become distressed, stop and write down your feelings till you feel calmer then resume the exercise or leave it for another time. Seek the help of a health professional if you feel you may harm yourself or others.
- Connect the dots of your memories in chronological order to get a zig-zag line effect around the central line.
- Leave the chart until another time when you have two hours to yourself.
- Examine your chart and answer the following questions in your notebook.
- How have I coped with positive and negative events in my life?
- Do I acknowledge my successes?
- How do I cope when under stress?
- Which are the most successful ways of coping for me?
- In what ways has my coping pattern altered since the trauma?
- Do I know of any coping strategies that would be helpful but I have not attempted yet?
- How do I cope with interpersonal relationships?
- Can I cope when alone?
- You may think of additional questions.
- From these make two lists: one of positive coping strategies and the other of negative coping strategies.
- Decide which strategies you want to continue to use and which you no longer want to use. Focus on increasing the positive and shifting away from the negative.
- Congratulate yourself on your successes.
- Dealing With Guilt
- Guilt arises from a responsibility for others. We focus on the harm or hurt we may have caused other people. It is often connected to fear and sadness.
- Normal guilt occurs when we think we have done something wrong, and pathological guilt occurs when we have the additional belief that as a result we are a bad person.
- We may resort to self-punishment because we feel that we deserve to be punished since we are a bad person. A common form of self-punishment is self-blame where we blame ourselves entirely for problems. We may take self-blame further and self-harm.
- The problems of life naturally cause guilt which can restrain us but on the bright side, can enable us to acknowledge our damaging behaviour.
- Guilt can trigger self-attacking and shame.
- Guilt occurs when we feel we have not dealt adequately with people, had to turn down their requests or suffered a separation.
- If you suffer guilt because you may think you are a burden or feel you have disappointed others, note that you do not choose to have your emotional problems. If your guilt makes you feel suicidal seek professional help.
- Try to recognize your key guilt areas.
- Let us consider how guilt can be both beneficial and detrimental to your well-being. Write down the ways in which recognizing your guilt helps you. Then think about the ways in which it is not of aid.
- Confront and challenge your guilt by asking yourself the following questions: What am I trying to achieve by endeavouring to be pleasant? Am I taking on too much responsibility? Is this something I learned when young and need to alter now? What made me think this way and how might I alter my behaviour? Does my guilt make me submissive and unable to assert myself for fear of what others may think? What evidence is there for and against my guilt? What are the alternatives to my negative thoughts about guilt? What advice would I give a friend experiencing the same circumstances? How can I reduce and control my guilt?
- It can be helpful to write a review of how you think you may have acquired your guilt and what you could do to challenge your guilty thoughts.
- List the advantages and disadvantages of feeling guilty in a given situation.
- How does guilt benefit your life? How is it detrimental to your well-being?
- List all the factors that contribute to your problem.
- Dealing With Grief
- You need to acknowledge and grieve properly for any loss you may have experienced.
- List the number and type of losses you have experienced in your life so far.
- Answer the following questions in your notebook:
- In what ways have you coped with loss in the past? Did you allow yourself to grieve?
- Did you mark the loss with a memorial ritual?
- Did you attend funerals for losses involving death?
- What has been your most difficult loss? Why was this so hard for you?
- Do you feel there are still things that can be done to honour your loss?
- What was your most helpful coping strategy for dealing with the loss?
- In what ways was your coping behaviour unhelpful?
- Looking back, are there things you would have done differently?
- Did you experience feelings of shock and disorientation perhaps accompanied by a period of denial? Was the loss too painful for you to admit? Did you diminish the loss? Did you feel numb and unconnected to what was occurring around you?
- Is it difficult to admit your loss, even now? Does your loss feel real now and is that hard to cope with?
- Have you experienced angry feelings towards others who have made unhelpful comments about your loss? Are you ashamed of these feelings and are they stopping you from moving forward? Write down the worst comments that have been made about your loss. Put this list away knowing just how dense people can be!
- As you struggle with your despair, everyday stresses may feel like too much to cope with. Make a deal with yourself to not take any drastic actions until you can manage better.
- You may feel reluctance at enjoying life again. You may find it hard to say goodbye but try to think of memorial rituals to use for your traumatic situation.
- If your feelings of loss are not healing, seek some professional help.
- Living With Physical Pain
- You may have physical scars as well as emotional scars and you need to adjust to these changes in your body.
- Consider your life before the trauma. Write down all the things you used to be able to do. Rate how your quality of life was in the past using a score of 0-10 (0 is very low and 10 is extremely high quality of life).
- Note what sorts of things you are able to do now and rate your current quality of life.
- Write down the difference, if any between the two scores.
- Think of all the changes you could realistically make to improve your quality of life. Give your desired quality of life a score of 0-10.
- List these changes in order of difficulty. Starting with the easiest, consider the steps you need to take to achieve your target. It may be helpful to ask a friend for support in making these changes.
- You need to learn to accept your new body image:
- Everyday for a week spend 5-10 minutes examining and familiarizing yourself with different parts of your body starting with areas which have not altered much to those parts which have greatly changed.
- Write a letter of appreciation to the different parts of your body.
- Show acceptance of your body by buying the different parts inexpensive but pleasurable gifts such as cream or ribbon, for massage or decoration.
- There may at present be no medical solution to your pain but you can learn to control it.
- Write down the activities you no longer do because of the pain you experience.
- Choose one or two of the activities you would like to resume or a new activity you would like to start, and consider how you might achieve this objective. Plan towards your goal in small steps.
- You could try transforming your pain in your imagination:
- Consider the colour, shape, size and texture of your pain. How does it feel? Is it solid or liquid? Is it hot, warm or cold? Does it make a noise? Where in your body is it located?
- Now imagine altering this image to lessen your pain. You could make it smaller, smoother and more soothing in colour or allow the pain to flow out of your body as a liquid.
- Rate the intensity of your pain before and after you do this exercise using a score of 0-10 (0 is no pain and 10 is extreme pain). Keep a record of these scores in a diary which will enable you to see your improvement.
- Practice this exercise as often as possible.
- Problem-Solving
- Problems of any sort can cause a person to become distressed, frustrated and angry.
- The problem-solving approach can be useful in these cases. You learn to focus your thinking and find solutions to your problem instead of becoming angry. There are six steps in problem-solving:
- Define the Problem – Be specific and try to break the problem into more manageable tasks. Do one task at a time. Choose your task and specify your goal.
- List Solutions – Try to write down as many ideas, to solve your problem, as you can.
- Evaluate the Pros and Cons of Each Solution – Consider your solutions and reject the unsuitable ones. List the remaining solutions in order of usefulness.
- Selecting a Solution and Planning Action - Choose your first solution and decide how you will put it into action. Rehearse your task and make sure you have a back-up plan in case your task does not go as planned.
- Do it - Attempt your solution.
- Review the Result of the Solution – If your solution is successful try to understand why it was so. If your solution is unsuccessful try to comprehend why it did not work. Praise yourself for having tried and choose your next solution from your list.
- Assertiveness Training
- The aim of assertive behaviour is to stand up for your legitimate rights and face others without putting yourself or them down.
- Assertiveness training teaches you to increase the number and variety of situations in which you are assertive.
- There are three types of interpersonal behaviour:
- Aggressive - you may be forceful in expressing your opinions, feelings and wants.
- Passive - your opinions, feelings and wants may be withheld completely or partly.
- Opinions, feelings and wants are stated with respect for the rights of others.
- Make sure you are aware of your fundamental rights which include: asking for what you want; saying 'No' without guilt; not being perfect; being ignorant about something; being responsible for your actions; having your own perspective and emotions; being indecisive; choosing whether or not to deal with others' difficulties; expecting privacy, independence and success.
- There are five steps to being assertive:
- What do you want? ;
- What is fair? ;
- Be clear in asking for it;
- Contemplate and be ready for the risks;
- Stay calm
- Practice your arguments in advance and repeat yourself to get the message across. Be prepared to negotiate.
- Think about situations in which you are not assertive and how you could change this and be assertive.
- Write out a detailed description of problem scenes - note when and where the problem occurs; who is involved; what your difficulties are; how you handle it; your fear of what will happen if you are assertive; your goal.
- To deal with a problem situation:
- Consider your rights and wants.
- Unless spontaneous action is required, arrange a mutually convenient time to discuss your problem with the other person.
- Define the problem as specifically as possible.
- Describe your feelings using 'I' messages, to give the other person an understanding of how important the issue is to you.
- Make your request in one or two simple but firm sentences.
- Give positive reinforcement to get what you want e.g. we'll be able to spend more time together. If this will be ineffective try negative reinforcement, describing the alternative way you will look after yourself if your wishes are not met.
- You need to arrive at a workable compromise. Agree to review this after a specified length of time and if you are not both satisfied you can renegotiate.
- Avoid being manipulated - techniques include:
- 'Broken Record' where you choose a concise assertive statement to say over and over to get your message across.
- Delay responding to a challenging statement until you are more prepared.
- Inviting criticism may reveal what is troubling the other person.
- When someone puts you down, acknowledge something you can agree with in their criticism and ignore the rest.
- You can change the focus, from discussing the topic to analyzing the interaction between the two of you.
- In instances where you lack time you could use the short form assertiveness technique. Consider:
- Your thoughts - state the facts as: 'I think…'
- Your feelings - express as 'I' statements: 'I feel…'
- Your wants - specify behaviour change as: 'I want…'
- You need to develop assertive body language. Practice the following basic rules in front of a mirror so that you learn how to apply them to problem situations:
- Maintain eye contact and an erect body posture.
- Speak clearly and firmly.
- Emphasize what you are saying with gestures and facial expressions.
- Learn to listen assertively:
- Make sure you are both ready to listen.
- Listen giving the other person your full attention and ask them to clarify if necessary.
- Let the other person know you have heard what s/he has expressed to you.
- Practice being more assertive in problem situations and consider how it makes you feel.
- Role-playing is a good way to improve your assertiveness in a safe environment before trying it out in real life situations.
- Conclusion
- The path to recovery is a very long one.
- You may find it difficult to forgive yourself or others. While premature forgiveness may be detrimental, forgiveness allows you to move on.
- Use visualization to enhance your recovery.
- You could try the following method of visualization:
- Ensure you have some time to yourself and push your worries to one side.
- Sit or lie comfortably and close your eyes with your arms by your side.
- Concentrate on breathing naturally.
- Place your hands on your stomach and breathe in deeply and hold for a few seconds feeling your stomach rise. Breathe out and feel your stomach contract. Repeat and as you breathe out think of a relaxing image or sound. Continue doing this until you feel thoroughly relaxed.
- Now visualize the future – how are you? Where are you? See clearly your surroundings – how do you feel? Feel acceptance of yourself and become aware of your strength and courage.
- Count back from 10 then open your eyes - slowly get up and resume normal activities with confidence in your ability to move forward.
- If, despite all of your efforts, you still feel unable to cope, you need to seek professional help.
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