Experience of a traumatic event can shatter a person’s life, leaving him or her feeling vulnerable and frightened. It is very important to remember that recovery is possible and that you can lead a normal, happy life again. This does not mean that you will forget what happened to you or that you will never again be distressed by memories and reminders of the event. A certain amount of distress when you think about what happened is part of being a normal, caring human being and we certainly do not want you to have no feelings. However, the distress will become less frequent and more manageable – it will no longer control your life as it may do now. Recovery also does not mean that you will be exactly the same person that you were before the trauma. Such powerful experiences may change people in many ways, not all of them negative. As people recover from trauma, they may find themselves stronger than before, perhaps more caring and with a more balanced and sensible view about what is important in their lives.

By seeking some help, you have taken the first steps to recovery. The purpose of this Manual is to help you through the treatment process in a step-by-step fashion. There is a great deal of information here – take it slowly and read each section as often as necessary until you understand it before moving on. You will be asked to write things down from time to time, so we suggest that you find an exercise book to use for those tasks that you will keep adding to throughout your recovery. Try not to worry if it all seems too difficult at the moment – recovery from trauma is often a long process and you need to take things one day at a time, recognizing small improvements as they occur. It can be a long journey, but it will be worth it.

The nature of traumatic stress and posttraumatic stress disorder

At some point in our lives, nearly all of us will experience a very frightening or distressing event that will challenge our view of the world or ourselves. Virtually everyone develops some kind of psychological reaction following such experiences – this is part of a normal human response to extreme stress. Most people will recover over the weeks and months following the incident, with the help of caring family members and friends. For some, however, recovery does not come so easily and more serious problems develop. In those cases, professional help is often required.

Some individuals who experience a traumatic event will go on to develop a chronic condition known as posttraumatic stress disorder. The exact numbers are difficult to specify, but anywhere between 5% and 40% of trauma survivors may develop Posttraumatic stress disorder. The question of why some people are affected more than others has no simple answer – many factors are involved. It seems to be a complex mix of what the person was like before the trauma, his or her experience of other frightening events in the past, the severity of the current trauma, and what else is happening as he or she tries to recover. Regardless of the causes, effective treatment does a great deal to improve the chances of recovery.

What is a traumatic event?

Trauma is a very personal thing. What traumatizes one person can be of less significance to others. This variation in people’s reactions occurs because of their individual personality, beliefs, personal values, and previous experiences (especially of other traumatic events in their life). It occurs also because each person’s experience of the incident is unique. However, in all cases the individual has experienced a threatening event that has caused them to respond with intense fear, helplessness, or horror. The threat or injury may be to themselves or to others close to them. Typical traumatic events may be of human origin (such as war experiences, physical assault, sexual assault, accidents, and witnessing the death or injury of others) or of natural origin (such as bushfires, earthquakes, floods, and hurricanes). Overall, there are no hard and fast rules to define trauma.

What is posttraumatic stress disorder?

Posttraumatic stress disorder is a psychological response to the experience of intense traumatic events, particularly those that threaten life. It can affect people of any age, culture or gender. Although we have started to hear much more about it in recent years, the condition has been known to exist at least since the times of ancient Greece (more than 2000 years ago) and has been called by many different names. In the American Civil War it was referred to as “soldier’s heart”, in the First World War it was called “shell shock”, while by the Second World War it was known as “war neurosis”. In civilian life, terms such as “shock neurosis”, “railway spine”, and “rape trauma syndrome” were used in the past.

Traumatic stress can be seen as part of a normal human response to intense experiences. While most people recover over the first few months, for many the symptoms do not seem to resolve quickly and, in some cases, may continue to cause problems for the rest of the person’s life. It is also common for symptoms to vary in intensity over time. Some people go for long periods without any significant problems, only to relapse when they have to deal with other major life stress. In rare cases, the symptoms may not appear for months, or even years, after the trauma.

Common symptoms of posttraumatic stress disorder

Posttraumatic stress disorder is characterized by three main groups of problems. They can be classified under the headings intrusive, avoidant and arousal symptoms.

Intrusive symptoms

Memories, images, smells, sounds, and feelings of the traumatic event can “intrude” into the lives of individuals with Posttraumatic stress disorder. Sufferers may remain so captured by the memory of past horror that they have difficulty paying attention to the present. People with Posttraumatic stress disorder report frequent, distressing memories of the event that they wish they did not have. They may have nightmares of the event or other frightening themes. Movement, excessive sweating, and sometimes even acting out the dream while still asleep may accompany these nightmares. They sometimes feel as though the events were happening again; this is referred to as “flashbacks”, or “reliving” the event. They may become distressed, or experience physical signs such as sweating, heart racing, and muscle tension, when things happen which remind them of the incident. Overall, these “intrusive” symptoms cause intense distress and can result in other emotions such as grief, guilt, fear, or anger.

Intrusive symptoms of Posttraumatic stress disorder

•  Distressing memories or images of the incident

•  Nightmares of the event or other frightening themes

•  Flashbacks (reliving the event)

•  Becoming upset when reminded of the incident

•  Physical symptoms, such as sweating, heart racing, or muscle tension when reminded of the event

Avoidance symptoms

Memories and reminders of traumatic events are very unpleasant, causing considerable distress. Therefore, people with Posttraumatic stress disorder often avoid situations, people, or events that may remind them of the trauma. They try not to think about, or talk about, what happened, and attempt to cut themselves off from the painful feelings associated with the memories. In their attempts to do this, they often withdraw from family, friends, and society in general. They begin to do less and less, no longer taking part in activities they used to enjoy. This may help them to shut out the painful memories, but it can also lead to feelings of isolation and of not belonging to the rest of society. In this way the person can become “numb” to their surroundings and not experience normal everyday emotions such as love and joy, even towards those close to them. Such reactions can lead to depression and problems within the family. They can also lead to severe problems with motivation – people with Posttraumatic stress disorder often find it hard to make decisions and to “get themselves going”. They may have difficulty making the effort to help themselves or even to do things that they would previously have found enjoyable or easy. This can be very hard for family and friends, who often think that the sufferer is just being lazy or difficult.

Avoidance and numbing symptoms of Posttraumatic stress disorder

•  Trying to avoid any reminders of the trauma, such as thoughts, feelings, conversations, activities, places and people

•   Gaps in memory – forgetting parts of the experience

•   Losing interest in normal activities

•   Feeling cut off or detached from loved ones

•   Feeling flat or numb

•   Difficulty imagining a future

Arousal symptoms

People who have experienced a trauma have been confronted with their own mortality. Their assumptions and beliefs that the world is safe and fair, that other people are basically good, and that “it won’t happen to me”, have been shattered by the experience. After the event, they see danger everywhere and become “tuned in” to threat. As a consequence, they may become jumpy, on edge, and feel constantly on guard. This can lead to being overly alert or watchful and to having problems concentrating (e.g., not able to read a book for long, getting only a small amount of work completed in a few hours, easily distracted). It is common for sleep to be very disturbed – difficulty getting off, restlessness through the night, or waking early. Sometimes people find that they are frightened to go to sleep because of the nightmares or because they feel unsafe.

Anger is often a central feature in Posttraumatic stress disorder, with sufferers feeling irritable and prone to angry outbursts with themselves, others around them, and the world in general. In part, the anger is one way of expressing the feelings of being tense and on edge that are associated with Posttraumatic stress disorder – for some people it is easier to acknowledge anger than fear. In addition, however, this anger results from the feelings of injustice caused by the trauma – a reaction to the gross unfairness of it all. Anger and irritability frequently cause major problems at work, as well as with family and friends.

Arousal symptoms of Posttraumatic stress disorder

•  Sleep disturbance

•  Anger and irritability

•   Concentration problems

•   Constantly on the look out for signs of danger

•  Jumpy, easily startled

Associated problems

Posttraumatic stress disorder is not the only psychological response to trauma. People may develop a range of other problems that can affect their quality of life, their ability to relate to other people, and their capacity for work. These problems may occur on their own, or as part of the Posttraumatic stress disorder. Many of these problems are thought to be the result of people trying to control either themselves and their symptoms (such as alcohol and drug abuse) or their environment (such as avoidance behavior and angry outbursts). Also, many of the signs are directly related to stress (such as skin complaints and general aches and pains). Overall, the most commonly associated problems in Posttraumatic stress disorder are those relating to anxiety, depression, and alcohol or drug use – we will discuss each of these briefly. They can be very disabling to the sufferer, and may affect family members and work colleagues. Many of the following problems develop over time as the person struggles to cope with the Posttraumatic stress disorder. If you are in the early stages following a trauma, some of the following may not apply to you.

Anxiety

Anxiety is a state of apprehension and worry that something unpleasant is about to happen. It is often accompanied by a range of physical symptoms (such as sweating, racing heart, and breathing difficulties) that are, in themselves, very frightening. Sometimes people experiencing these symptoms believe that they are going to die from a heart attack or go crazy. Anxiety can be specific to certain situations (such as social events, crowded places, or public transport), or it can be a general state of worry about many things in our lives. If you are having significant problems in these areas, be sure to tell your therapist. Treatment can be very effective.

Depression

Depression is a general state of low mood and a loss of interest or pleasure in activities that were once enjoyed. Life becomes flat and gray, and nothing seems fun, exciting, or enjoyable anymore. These depressed states can be very intense, leading to a total withdrawal from others and a state of numbness, or they can be lower in intensity – just feeling “down in the dumps”. They may last for as little as a few hours or as long as months or even years. In more severe cases, the person may believe that life is no longer worth living. Many people who suffer from Posttraumatic stress disorder over a long period develop significant problems with depression. Again, it is important to tell your therapist if these problems apply to you. It can be treated effectively with psychological treatments and/or prescription drugs.

Guilt

People with Posttraumatic stress disorder often report strong feelings of guilt, shame, and remorse. This may be about the fact that they survived while others did not; it may be about what they had to do to survive; it may be related to how they have coped or acted since the trauma. Guilt is often the most difficult thing to talk about, especially if you feel that you did something wrong or acted in a bad way. However, it is very important that you work on those feelings as part of your Posttraumatic stress disorder treatment, so be sure to tell your therapist about those feelings.

Alcohol and drugs

In an attempt to cope with the unpleasant symptoms, many people turn to alcohol or other drugs. Although they may seem to help in the short term, they prevent the person from recovering effectively and lead to long-term problems. Drug and alcohol abuse impairs the person’s ability to function effectively and to relate to other people. It can cause great difficulties in areas such as relationships, work, finances, and violent behavior.

Impact on relationships and work

Traumatized people can become “consumed” by their feelings, which may lead others to believe that they are selfish, thinking only of themselves. Difficulty feeling and expressing emotions (e.g., love and enthusiasm), loss of interest in sex, and reduced participation in activities and hobbies that they used to enjoy before the trauma are common. Traumatized people are often tired and can become cranky and irritable. They may say hurtful things without really considering the implications of what they are saying. All of these symptoms may cause partners to feel rejected and unloved, and the absence of shared enjoyable activities makes it difficult to have a normal family life. It is very important to keep communicating about what is happening – try to be reasonably honest with each other about how you are feeling.

People with Posttraumatic stress disorder may have difficulty coping with pressure at work. Irritability, jumpiness, mood swings, poor concentration, and memory problems may lead to disputes in the workplace and frequent job changes. Some people with Posttraumatic stress disorder adopt a workaholic pattern, shutting themselves away in their work and putting in very long hours. This seems to be part of the avoidance component of Posttraumatic stress disorder -keeping very busy helps to prevent the memories and unpleasant thoughts coming back – but it does not help in the long term. Others find that their problems prohibit them from working effectively at all.

Why do traumatic stress reactions develop?

It is important to understand where the signs and symptoms of Posttraumatic stress disorder come from. One of the leading clinicians in the area, Mardi Horowitz, described trauma as an experience that is, by its very nature, overwhelming. It contains lots of new information that is hard to accept or understand. It does not fit with our view of the world or ourselves – the way we think things are or should be. Human beings have a natural tendency to try to make sense of things that happen around them. When people experience a trauma, the event keeps coming back into their mind in an attempt to make sense of what happened. This is the body’s natural way of trying to deal with, or come to terms with, difficult experiences and seems to work well for many stressful life events. However, due to the high level of distress associated with memories of more severe trauma, the thoughts and feelings tend to be pushed away to protect the person from this distress. The result is that, whilst the memory may go away for a while, the need for it to be dealt with has not been addressed and it keeps coming back. The movement backward and forward from intrusive thoughts and feelings about the trauma to avoidance and numbing can then continue almost indefinitely unless the cycle is addressed in some way.

Throughout this alternating between short bursts of painful memories and periods of avoidance and numbing, the sense of feeling keyed-up persists. The traumatized person has been through an event that threatened their life, or the life of someone else, so the mind and body stay on alert to make sure that no future potential dangers will be missed. It is safer to get it wrong by overestimating potential threat than to risk the possibility of missing any future threat. The persistent activation of this threat detection system, however, leaves the traumatized person feeling keyed-up or on edge much of the time. In addition, the threat detection system is so sensitive that it is constantly going off when there is no danger in such a way that interferes with the person’s capacity to live a normal and happy life.

Traumatic stress reactions, therefore, are sensible and adaptive both as part of survival during the trauma and in attempts to come to terms with the trauma afterward. Once we recognize where these symptoms come from, it is easier to understand the typical traumatic stress reactions. The difficult part is letting go of these reactions now that they have ceased to provide benefit and are interfering with the traumatized person’s quality of life.

The process of treatment and recovery

You have already started the first stage of recovery by acknowledging your reactions to the traumatic event. Presumably, you have also taken the next step of seeking appropriate treatment from a mental health professional. Getting help is often frightening – for many it is a leap into the unknown – but trying to recover from Posttraumatic stress disorder on your own is much more difficult. Treatment usually involves several stages; we will go through each of these in turn.

Posttraumatic stress disorder: stages of treatment

1.  Crisis stabilization and engagement

2.  Education about Posttraumatic stress disorder and related conditions

3.  Strategies to manage the symptoms

4.  Trauma focused therapy (confronting the painful memories and feared situations)

5.  Cognitive restructuring (learning to think more realistically about what happened)

6.  Relapse prevention and ongoing support

It is important to remember that treatment can be painful and hard work. Unfortunately, there is no easy way to get rid of the memories or make them less distressing. There is no magic wand that your therapist can wave or tablet that you can take to make it all go away. But the long-term gains can be enormous: effective treatment can dramatically assist your recovery, helping you to live a normal life once again.

Stabilization of a crisis and engagement in treatment

People who have been through a trauma often have other difficult situations to deal with in the aftermath. These may be legal issues, family disruptions, financial problems, or a multitude of other crises. It is important that any current life crises are resolved, or at least put “on hold”, before the real treatment of Posttraumatic stress disorder can begin. It is not possible to devote the necessary concentration, time, and energy to your recovery if you are constantly worried about your job, your relationship, your children, or other important life areas. That is not to say that you have to be able to solve all those problems before you can work on your Posttraumatic stress disorder, but you will need to be able to put them to one side for a while to concentrate on your treatment. Therapy is hard work – there is no easy way to do it – and you will need to devote all your personal resources to the task. If other life issues are worrying you, it is important that you discuss these with your therapist as they arise so that they do not interfere too much with your treatment.

The first part of treatment will often be devoted to developing a relationship with the therapist (or the treatment team if you are taking part in a group program). You will need to spend some time getting to know each other, and building trust, if you are to work on the difficult issues. We call this process “engagement”. For many people with Posttraumatic stress disorder, this is a very difficult process -experience of a traumatic event often makes it very hard to trust another person, particularly someone whom you have never met before. In many cases, you will need to tell your therapist about experiences and feelings that you have never discussed with anyone. We need to recognize that this is a difficult process that will take a lot of courage, but it will be worth it and it is the only way to recovery.

Education and information

Posttraumatic stress disorder can sometimes feel like an incomprehensible cloud that hangs over all areas of the person’s life. The first step in treatment is to understand exactly what trauma is, why we have the symptoms we do and, therefore, why it is treated the way it is. In this regard, you have come a long way already by reading the sections above. You need to know what the common signs and symptoms are, and you need to recognize that you are not alone – many people who have experienced traumatic events have responded in exactly the same way you have. You need to understand why the symptoms have appeared – the fact that they were very useful for survival while the traumatic events were happening but that they are no longer useful. They have become “maladaptive” and now serve only to create problems and distress for you. You need to understand what treatment will involve and how it may affect you. It is very important that you feel able to ask your therapist questions about the nature of your problems and the process of treatment. He or she will not have all the answers, but together you will reach a better understanding of what has happened and how you will recover.

Sometimes people who have been through a traumatic event have trouble understanding what happened and why it happened. You may find yourself constantly asking questions such as “How did this happen” or “Why me?”. This is partly because, when we are under threat, our attention is very focused on the source of the danger and we do not take in all the other things that are happening around us. We may end up with a distorted and confused memory of the experience, so that it becomes difficult to understand and make sense of the event. This confusion often stops us from being able to put the experience behind us. For this reason, your therapist may help you to find out more about what happened during the event. This process is important in being able to “put the pieces of the jigsaw puzzle together” and make sense of your experience. A good understanding of exactly what happened, and why it happened, often facilitates recovery.

Although we have put this under the heading “Education and information”, it is actually something that may happen at several stages throughout treatment and you need to make sure that you are ready before you pursue these options. When you are feeling reasonably confident, however, ask yourself what other information you need to help you to understand what happened and why it happened.

•  Is there anyone else you can talk to who may be able to clarify things for you and help you to reach a better understanding of your experience (such as others who were there, police officers, or ambulance officers)?

•  Is there anything you can read that will help to fill in the missing pieces (such as media reports, police statements, or reports from a trial or coroner’s inquest)? Sometimes, reading accounts written by other survivors of trauma can be useful in understanding your reactions.

•  Occasionally there may even be video footage available from news reports or other sources: is there anything you can watch that will help you to fill in the gaps?

Unfortunately, of course, it is not always possible to fill in all the gaps in your understanding of the event. Sometimes we may never find out exactly what happened (or, more commonly, why it happened) and treatment needs to focus on helping us learn to live with that uncertainty.

Managing Anxiety and Distress

Exposure Therapy: Confronting Feared Situations

Exposure Therapy: Confronting the Memories

Cognitive restructuring

One effect that exposure may have is to bring to the surface unhelpful thoughts and beliefs that have arisen as a result of your experiences. In order to recover effectively from the trauma, it may be necessary to challenge those thoughts and beliefs (we call them “cognitions”), and try to replace them with something more rational and realistic. In Posttraumatic stress disorder, this process is best carried out in conjunction with the process of exposure, modifying the unhelpful cognitions as they arise.

Following a traumatic experience, people may be left with a range of negative thoughts about what happened, as well as about themselves and the world. For example, many people are left feeling vulnerable and insecure. They may think that the world has become a dangerous place and that other people are nasty, cruel, and out to take advantage. Similarly, many people experience feelings of guilt and shame following trauma. They may think that they are bad or evil for acting in the way they did during or after the incident; they may think that what happened was their fault; they may see themselves as weak or inadequate for not coping better. Sometimes, there may be elements of truth in these thoughts. Usually, however, they are completely untrue or, at least, grossly exaggerated. This kind of thinking leads to all sorts of unpleasant emotions such as depression and guilt, anxiety and fear, and anger. An important part of recovery involves identifying those maladaptive thoughts, challenging them, and replacing them with a more realistic view of yourself and the world.

Cognitive restructuring is a procedure whereby people’s thoughts, beliefs and interpretations about past experiences are identified and mistakes in thinking are highlighted. For example, it may be that the person is thinking in “black-and-white terms” – seeing things (or other people) as all good or all bad – when in reality the world holds much that is “gray”. It may not be perfect, but it’s not all bad either. The person may be overgeneralizing (e.g., “no-one can be trusted”) or overfocusing on the negatives and minimizing the positives about their situation. They may see one negative thing as confirmation that they are not coping, while ignoring other evidence that they are, in fact, coping quite well. A common problem in Posttraumatic stress disorder is that people base their interpretations about what happened, themselves, or the world upon only a fragment of the memory (the part that repeatedly comes back) rather than on information that places that aspect in a broader context. Once these faulty thought patterns are discovered, it is the goal of cognitive therapy to replace them with more adaptive, realistic and flexible beliefs. This, of course, includes re-evaluating our experiences and, in particular, the traumatic event. It is a difficult process that can take a lot of hard work, but it can be very effective in minimizing and managing unpleasant emotions.

The process of cognitive restructuring

As with several other components of treatment, the other Patient Treatment Manuals in this book contain some excellent descriptions of the process of cognitive restructuring. If you are working with a therapist, you may wish to ask him or her to copy some of the relevant sections for you. In this section, we will talk briefly about how to go about identifying and challenging your unhelpful thoughts with specific reference to trauma.

The task this time is to write at least one page on what your experience of the event means to you. In particular, how has it changed your beliefs, views, and ideas about yourself, other people, and the world? What views or beliefs have been strengthened? Which ones have changed? Try to write something under each of the following headings:

•  My beliefs about myself have changed since the trauma in the following ways.

•  My beliefs about other people have changed since the trauma in the following ways.

•  My beliefs about the world have changed since the trauma in the following ways. In answering those questions, you may want to think about issues such as how you feel about yourself (self-esteem), your personal safety, trusting others, thoughts about control and power, intimacy with others, what kind of society we live in, etc. Any ways in which you think the event has changed your ideas, thoughts and beliefs.

The next stage is to pick one of the key themes that is leading you to feel an unpleasant emotion. Which one makes you feel angry? Or frightened? Or guilty? Or sad? Try to express it as a single statement of opinion, such as “all men are bad” or “it was all my fault”. In particular, look for statements beginning with “I”, such as “I’m weak and hopeless” or “I’m not safe anywhere”. Write this thought or belief at the top of a clean sheet in your exercise book. Then go through and try to answer the following questions. Some of them may not apply to every thought, but most will – they will help you to re-evaluate whether your thoughts and beliefs are really true.

What is the evidence? Here we want you to become a scientist and really think about the objective evidence for and against the thought. Is it really true? Are you 100% sure? Do the facts of the situation back up what you think or contradict it? Write out all the evidence you can think of for and against the thought. In most cases, you will find that it is not completely true. (Indeed, it may turn out to be completely false.) What alternative views are there? How do other people think about this? Would other people agree with you? Is there another way of looking at it? Are there other explanations? Try to generate as many alternative explanations as you can and review the evidence for and against them. When you look at it objectively, which explanation is most likely to be correct? Am I thinking in all-or-nothing, black-and-white terms? Am I using terms like all, always, never? Nothing is all bad or all good, no person is either perfect or worthless. Try to look for a more balanced view, with a more realistic assessment of the situation. Am I overestimating my responsibility? Things happen for all sorts of complex reasons, many of which we may never understand. Be very careful not to take too much responsibility for things over which you do not have control. Are my judgments based on how I feel, rather than what is actually happening? If you feel guilty, you are likely to assume things must have been your fault. If you feel frightened, you may assume that you are not safe. If you feel depressed, you may assume that things will never get better. Feelings are not a good basis on which to make rational judgments. Put the feelings to one side for a moment and look for objective evidence. Am I over-focusing on one aspect and forgetting other aspects? Am I looking only at the negative side and ignoring the neutral or positive things? If we focus only on small parts of the whole picture, we will end up with a very distorted view of reality. How likely is it? Am I confusing a low probability with a high probability? How likely is it that what you fear will actually happen? Understandably, many trauma survivors fear a recurrence of the event but, realistically, how likely is it?

Am I underestimating what I can do about it? Am I putting myself in the role of helpless victim? What can I do to make things better or safer for myself? Taking some control – doing something about it – is an important part of recovery. What will happen if I continue to think like this? Is this kind of thinking helping me to recover? Will it help me to live a happy and relaxed life? Are there any benefits to thinking this way? If not, it is worth working hard to try to let go of the irrational negative thoughts.

When you have written an answer to all (or most) of the above questions, go back and reconsider the original thought. Do you still believe it? Is it still a rational statement of reality? If yes, try to go through the above process again – talking to others who can be more objective may help. Do not expect all the negative thoughts to disappear at once – it is hard work and you will need to go through the process many times to shift those ideas. If the thought does not seem entirely rational now, can you come up with a more realistic version of the original thought? Remember that we are not talking here about positive thinking – that is just as unrealistic and very fragile. We do not want to pretend that everything is rosy when it is not. We do not want to minimize what you went through. Equally, we do not want to overemphasize the negatives. Recovery is difficult, but you can make progress; life will not always be safe, but do not exaggerate the dangers. For example, if the original thought was “all men are bad”, a more rational alternative may be “some men are bad, but by no means all – most men are actually caring, safe, friendly people”. If the original thought was “I’m not safe anywhere” the rational alternative may be “I am safe in most places most of the time – I will be careful not to put myself in dangerous situations, but I do not need to worry constantly about getting hurt again”.

Relapse prevention

The final stage of treatment will look at relapse prevention. Recovery is not just about getting better; it is about staying better. Some simple strategies will help you to get through difficult times in the future. There are a few simple points to remember in relapse prevention:

• Lapses are to be expected from time to time: When you are reminded of your traumatic experience (such as hearing of a similar event, or experiencing something else frightening) it is natural for you to become a little distressed. This is part of a normal human reaction and, as long as it is not too severe or lasts too long, you should not consider it to be a problem. You can cope with being upset for a while. It becomes a problem if you are not expecting it and you tell yourself that you have “fallen in a heap” or that you are “back to square one”. Simply use it as a reminder to practice your coping strategies a bit more for a few days.

•  Be aware of the early warning signs: Keep an eye on yourself and try to notice when you are not coping so well. The earlier that you can recognize that things are not right, the easier it will be to do something about it. The longer you leave it, the worse it will get, and the more difficult it will become to pull yourself out again. It will be easier to recognize the early warning signs if you are aware of the kinds of things that may precipitate a lapse.

•  Identify high risk situations: Spend some time thinking about what kinds of things may cause you to become upset – the more prepared you are, the better you will cope. The kinds of things that upset most trauma survivors are powerful reminders or news of similar incidents, an experience similar to the original trauma, and other life stresses such as financial or family problems. What kinds of things may cause you to become upset and think about the trauma again?

•   Generate a plan to cope: Write down on a card what you will do if and when you are upset again about the trauma. The kinds of things to include are:

•   Who will you call? Write down the names and phone numbers.

•  Physical coping strategies: Which arousal management strategies worked best for you? Write down one or two (such as breathing control, go for a walk, listen to the relaxation tape) as a reminder to do them.

•  Cognitive coping strategies: Write out a coping self-statement that you can use such as “I expect to feel upset when I’m reminded of what happened, but that’s okay -1 may not like it but I can cope with it. I don’t have to make it worse by exaggerating it. Now, what can I do to make myself feel better?” You may wish also to jot down any other strategies that worked well for you such as your favorite distraction technique or thought stopping.

•  Behavioral coping strategies: Write down one or two things you can do to get you back on track – visit a friend, go to a movie, get involved in an engrossing hobby or task.

•  Be positive: Remind yourself that you expected this from time to time and that you will get over it quickly. Try to view it as an opportunity to practice your skills and become a stronger person.

•   Get professional help if necessary: No matter how well you have recovered from the original trauma, sometimes a relapse may be just too much for you to cope with alone. Don’t hesitate to get some professional help if necessary. It does not mean that you are weak or that you are back to square one, simply that you need some extra support to get over a difficult time. It may require only one or two sessions.

Hints for coping

The following is a list of tips that many people find useful. Do not try to do everything at once. When you have read the following sections, you may wish to stop for a while and work out a “plan of action”. Which strategies sound particularly useful for you? Which ones are you prepared to try? We suggest that you select only one or two to begin with. Work out a plan to achieve them, one at a time, and set yourself some realistic goals for the next week. At the end of the week, review your progress: modify your goals if necessary and/or try some additional strategies for the following week. Over time, you will gradually develop a range of coping strategies and changes to your lifestyle that will help you to feel more in control of your symptoms and get more out of life.

•  Eat healthy meals. This sounds so simple, but how many of us actually do it? A poor diet (especially junk food with lots of sugar) will increase your stress levels – if in doubt, talk to your general practitioner or a dietician.

•  Get regular aerobic exercise such as walking, jogging, swimming, or cycling. Exercise is very effective in managing stress. If you have Posttraumatic stress disorder, your body is constantly geared up for “fight or flight”. Exercise helps to burn up those chemicals (like adrenaline (epinephrine)) that are hyping you up and it will help you to become more relaxed.

•  Get enough rest, even if you can’t sleep. Rest will help to increase your reserves of strength and energy.

•  Establish, and try to stick to, daily routines (e.g., go to bed and get up at a set

time, plan your activities for the day). Routine is very important in helping us to feel in control and to function effectively. If you feel able, return to work, study, or other routines as soon as possible but take it easy – don’t expect too much of yourself and don’t use work as a way of avoiding painful feelings.

•  Ask for support and help from your family, friends, church, or other community resources when you need it. This is not a sign of weakness. In general, other people are very keen to help as long as you let them know what you want. If they do not offer, it may simply be because they are unsure of what to do.

•  Spend time with other people, but don’t feel that you have to talk about the trauma. Talk about football, books, or the weather; go to a movie or a concert; try to do some enjoyable things with others. This is part of resuming a normal life.

•  Focus on your strengths and coping skills. It may not feel like it at times, but you have many strengths and strategies to deal with difficult times. Remember that you are not alone. Many other survivors over the centuries have experienced these kinds of problems and the vast majority have recovered well.

Hints for family and friends

Partners and close friends are often at a loss as to how to help someone with Posttraumatic stress disorder. There are several things that loved ones can do to help the traumatized person. You may find the following suggestions useful.

•  If possible, listen and empathize when the traumatized person wants to talk. Remember that it may be very hard for them to express what they are going through. A sympathetic listener is important in minimizing the tendency of people with Posttraumatic stress disorder to withdraw and “shut down”.

•  It is best not to say “I understand what you’re feeling” (you probably don’t, since you haven’t been through the same experiences). Instead, show your empathy by comments such as “it must be really difficult for you; I can see that it upsets you; is there anything I can do to help?”.

•  Spend time with the traumatized person. There is no substitute for personal presence. Just keep doing the usual things that people do together. Do not feel that you have to talk about the trauma or be their counselor. Just being with people who care about them is very important for traumatized individuals. Equally, try to respect the person’s need for privacy and private grief at times.

•  Don’t tell survivors that they are “lucky it wasn’t worse” or to “pull themselves together and get over it”. They are not consoled by such statements. Tell them, instead, that you’re sorry they were involved in such an event, and that you want to understand and assist them.

•  Re-assure them that they are now safe.

•  Care about each other. Give hugs. Tell each other how much they are appreciated. Offer praise. Make a point of saying something nice to each other every day. Good relationships are characterized by lots of positive interactions, but they require hard work.

Hints for sleeping better

Sleep disturbance is very common in both Posttraumatic stress disorder and depression. Medication sometimes helps, but it should be used with caution and only as directed by your medical practitioner. There are several simple “nondrug” strategies that you can try that can be very helpful in improving sleep.

•  Get into a regular routine. In particular, get up at the same time each morning even if you haven’t slept well.

•  If you are not asleep within 30 minutes, get up for a while before returning to bed. If you don’t drop off within 30 minutes, get up again and so on.

•  Try to avoid caffeine (coffee, tea, cola, chocolate) from 6 p.m. onwards. Avoid alcohol and, if possible, cigarettes from dinnertime onwards. Try not to eat a meal within a couple of hours of going to bed.

•  Starting a gentle exercise routine and losing some weight often helps with sleep.

•  Don’t do anything in bed except sleep (and, perhaps, sex): don’t watch TV, read, do crosswords, or think about worrying things. Reserve bed for sleeping.

•  Get into the habit of doing something relaxing before bed: listen to a relaxation tape or some relaxing music, have a warm bath, slow down!

•  Try not to worry about not sleeping: the more you worry about it, the less likely you are to drop off to sleep. You can survive without much sleep, even though you will be tired.

•  Sleep, like any habit, takes a while to change. Try to stick to the above guidelines for at least 2 weeks before deciding whether or not they help.

Overview of anxiety management

When we experience a very frightening or unpleasant event, our body gears itself up to fight the threat or to run away (the “fight or flight” response). If the threat is small and passes, our body quickly returns to normal. If the threat has been major, however, or if there is ongoing danger (or stress), our body remains in a state of alertness ready to react immediately if the threat reappears. This chronic state of alertness affects us in many ways. First, we tend to stay physically hyped up and aroused all the time. Our heart rate and breathing are increased, and our muscles remain tensed up, leading to all sorts of unpleasant physical sensations, aches, and pains. Second, our thinking is affected. We may find it hard to concentrate, remember things, and make decisions. Memories of the trauma, or thoughts of future danger, seem to constantly come to mind even when we do not want them to. Third, our behavior is affected. Experience of the trauma, as well as the unpleasant signs and symptoms that may follow, causes people to feel scared and vulnerable. In an attempt to cope, they may try to withdraw from other people and the outside world, shutting down as a means of self-protection. If we are to effectively manage the anxiety and distress that follows a traumatic experience, we will need to address all three aspects: the physical components, the thoughts, and the behavior.

It is important to remember that the goal is not to make the unpleasant feelings go away altogether – that is neither possible nor desirable. Rather, the goal is to keep them manageable – to keep them under control and to stop them escalating into extreme anxiety and panic. Practice is essential to master most of the following techniques. Try to set aside some time each day (preferably twice a day) to practice. If you wait until you are tense and frightened before you try the technique, it will not work. Once you have practiced them regularly, however, they will become more automatic and effective. They will become important tools in helping you to manage anxiety and distress. Keep a diary of your practice sessions, noting down the Subjective units of distress level before and after. This will give both you and your therapist a good idea of how you are progressing.

The following sections discuss strategies in each of the three domains. Other chapters in this book contain very good descriptions of several anxiety-management strategies. You may wish to talk to your therapist about getting copies of some of the relevant sections.

Subjective units of distress

As you start to conquer your fears, it becomes very important to have a means of measuring your level of anxiety and distress. We suggest that you use a Subjective units of distress scale ranging from 0 to 100 – a kind of fear thermometer – where 0 is feeling perfectly relaxed and 100 is the worst anxiety and distress you can imagine. It is useful to get into the habit of rating your anxiety. That way you become more in touch with your feelings and have a better chance of controlling them. Without some kind of measure, people tend to think in black-and-white terms – you are either anxious or relaxed – when, in reality, there are many shades of gray. Using the Subjective units of distress scale will help you to keep your distress level in perspective, e.g., you may be feeling anxious, but it’s only 40 – you can handle that. In the exercises that follow, try to rate your distress (using the Subjective units of distress scale) before you try the anxiety-management strategy and again afterwards. We hope it will have come down (if only a little).

Managing the physical symptoms

Several strategies will assist in managing the unpleasant physical symptoms associated with traumatic stress and Posttraumatic stress disorder. Some of these have been discussed above under the heading “Hints for coping”. If you can get some regular gentle exercise, eat properly, get enough rest, and try to cut down on stimulants (such as coffee, tea, cola, chocolate, and cigarettes), you will go a long way towards reducing the chronic arousal that is part of Posttraumatic stress disorder. In this section, we will look at two specific strategies to reduce arousal. The first is a simple breathing control strategy designed to reduce your rate and depth of breathing and help you to feel more relaxed and in control.

Often when people are frightened or upset, they start to breathe faster. An increase in breathing is part of the fight or flight response – we need more oxygen if we are to fight or run away. However, breathing too deeply and too fast when we are not using up a lot of energy tends to make us more anxious and often causes unpleasant physical symptoms such as dizziness, tightness in the chest, and a feeling of being short of breath. When we are upset, we may be told to “take a few deep breaths”. However, this is not quite right. When we are feeling anxious or frightened, we don’t need to take a deep breath; we need to take a normal breath in and exhale slowly. Breathing out is associated with relaxation, not breathing in. While concentrating on a long, slow exhalation, it’s a good idea to say a word like “relax” or “calm” to yourself. Any word that is associated with feeling peaceful and at ease will do fine. Try to drag out the word to match the long, slow exhalation, as in “r-e-e-e-1-a-a-a-x” or “c-a-a-a-a-a-1-m”.

The next thing to remember is to slow your breathing down. Remember that taking in too much air causes an increase in anxiety and unpleasant physical symptoms. So, what we need to do is to slow our breathing down and take in less air. We do this by taking smaller breaths and by pausing between breaths to space them out. It is also important to try to breathe in through your nose, not through your mouth. When you have taken a normal breath in through your nose, hold your breath for a count of 4 before exhaling slowly.

Now, try putting it all together:

•  Take in a normal breath through your nose with your mouth closed.

•   Pause briefly while you count to 4.

•  Exhale very slowly (mouth open or closed, whichever feels most comfortable).

•  Say “calm” or “relax” to yourself as you exhale.

•   Repeat the whole sequence 6 to 10 times.

Practice this type of breathing at least twice a day. That way, when you become frightened or anxious, you will be ready to use the technique to help you to calm down.

The second physical intervention we will discuss is relaxation training, or progressive muscle relaxation. The breathing control described above, once you have mastered it, is an excellent strategy for dealing with rapid increases in anxiety that may occur when you experience memories of the trauma or find yourself in a frightening situation. Progressive muscle relaxation is designed to deal with the more pervasive, chronic tension and stress associated with Posttraumatic stress disorder. If you can lower your general level of arousal or “uprightness”, you will be much less likely to overreact in response to minor perceived threats. This is just like a coiled spring – the more wound up it is, the more likely it is to explode under pressure. The world will seem like a safer place.

Progressive muscle relaxation is usually done by listening to a tape, which will take you through a series of exercises in which you will be asked to tense up and relax various muscle groups. By gradually working through your whole body, from head to toe, you will achieve a state of physical relaxation that, with practice, you will be able to maintain through much of the day. Your therapist will make a tape for you to use at home. Alternatively, many libraries or community health centers will be able to provide one for you. Excellent descriptions of relaxation training appear in other Patient Treatment Manuals contained in this book and will not be repeated here. If you decide to try this approach (and we strongly recommend that you do), ask your therapist to copy one of the relevant sections for you. Making relaxation a regular part of your daily routine will go a long way to help you in managing the physical symptoms of Posttraumatic stress disorder.

Managing problems with thoughts

People with Posttraumatic stress disorder are often troubled with memories or other unwanted thoughts about the trauma. It is important that you do not try to get rid of these thoughts and memories completely- thinking about what happened is an important part of coming to terms with it and putting it behind you. Equally, it is not helpful to be thinking about it all the time – that simply causes unnecessary distress and prevents you from getting on with your life. So it is a good idea to learn a few strategies to control these unwanted thoughts so that you can limit them to times that do not interfere too much with other activities.

Distraction

One simple way that, with practice, can be very effective is distraction. An obvious example would be getting on with an activity that is absorbing (and we hope enjoyable) to occupy your mind. Can you think of something that you could do to distract yourself? Passive activities (like reading, or watching TV) do not usually work, as your concentration may not be good enough. Rather, you will need to do something more active that involves both physical and mental aspects. Games, crafts, and other creative activities are often good.

It is also good to practice a purely mental distraction technique that you can use anywhere, anytime. There are many things that you could try and the following list provides some examples. They are particularly good because no-one else can see you doing them. Do not try to do them all – pick one or two that feel as though they may work for you and practice regularly. Even with practice, you must expect the thoughts to intrude again from time to time. That’s OK – just go back to the distracting thoughts as often as necessary.

Strategies for mental distraction

•   Count and relax: Breathe normally, as you might when you’re just about to drop off to sleep. As you breathe in, count to yourself. As you breathe out, say “relax” to yourself. That is to say, when you breathe in, think “one”; as you breathe out, think “relax”; as you breathe in, think “two”, as you breathe out, think “relax”; as you breathe in, think “three”, and so on for 10 slow breaths several times a day. Don’t worry if other thoughts intrude, just go back to the count and relax.

•  Focus on a small area (e.g., a square meter (3 foot X 3 foot) on the wall opposite), or on an object, and describe it in minute detail – every line, shadow, and shape.

•  Focus on your surroundings with all senses: describe in detail to yourself what you can see around you, what you can hear, what you can smell, what you can feel (sensory perceptions of touch, not emotions or anxiety symptoms). Try to describe five things you can see, five you can hear, five you can feel, and so on. This is particularly good as it keeps you in touch with reality “here and now”.

•  Mental exercises: e.g., counting backwards to yourself from 100 in 7s or naming an animal beginning with each letter of the alphabet.

•  Describe to yourself in great detail a happy experience from the past (e.g., a holiday, a family occasion, a favorite walk). Try to go through every aspect from start to finish.

•  Describe in detail a place (perhaps from your past) where you feel safe, secure, relaxed, and happy. Where is it, what does it look like and smell like, who is there with you, what time of day is it, how does it feel, and so on.

Thought stopping

Another strategy to deal with unwanted thoughts and memories is known as “thought stopping”. This is a simple technique, but surprisingly effective if you are troubled by constant thoughts or “ruminations” about the trauma – if you find yourself thinking about what happened (or might have happened) over and over again. (Note: It should not be used for the brief and very vivid memories that jump into your mind for shorter periods of time.) If you wish to try thought stopping, practice it several times in the following manner. Place an elastic band round your wrist. Now, deliberately bring the unwanted thoughts into your mind and let them run for a minute or so. Then shout the word “STOP!” loudly (it’s best to practice this one on your own!) and snap the rubber band against your wrist. This will interrupt your train of thought. Repeat this process over and over again, gradually saying “stop” more and more quietly until eventually (after a dozen or so times) you are whispering it and then saying it just to yourself in your head. Keep snapping the band each time. If you practice that whole process a couple of times a day for several days, you will gain much more control over your thoughts. You will be able to stop the thoughts when you are in public without saying anything out loud (although you may wish to keep the rubber band there for a while as a reminder).

Self-statements

One final area we would like to discuss under the heading of managing thought problems is that of “self-statements”. At present, it is likely that many of your thoughts are negative: worrying about the safety of yourself or others, concerned that you will never recover, and so on. These negative thoughts feed into your anxiety and distress, making it much worse. We will address this issue again later. For the time being, we are going to suggest that you simply work out some simple things that you can say to yourself to help you calm down and relax when you are in a difficult situation or when you are feeling overwhelmed by painful memories. A famous psychologist, Donald Meichenbaum, has suggested that we should break up each event into several stages.

Examples of self-statements for coping with stress

1.  Preparing for a stressor

•  What is it I have to do?

•  What is the real likelihood of anything bad happening?

•   Don’t focus on how bad I feel; think about what I can do about it.

•   I have the support of people who are experienced in dealing with these problems.

•   I have already come a long way towards recovery; I can go the rest of the way.

2.  Confronting and handling a stressor

•   One step at a time; I can handle this.

•   Don’t think about being afraid or anxious, think about what I am doing.

•  The feelings I’m having are a signal for me to use my coping exercises.

•  There’s no need to doubt myself. I have the skills I need to get through.

•   Focus on the plan. Relax … breath easily; I’m ready to go.

3.  Coping with feelings of being overwhelmed

•  Take a gentle breath and exhale slowly.

•   Focus on what is happening now, not what might happen; what is it I have to do?

•   I expect my fear to rise, but I can keep it manageable.

•  This will be over soon. I can do it.

•  This fear may slow me down, but I will not be incapacitated by it.

•   I may feel nauseated and want to avoid the situation, but I can deal with it. 4.  Reinforcing self-statements

•   It was much easier than I thought.

•   I did it – I got through it; each time it will be easier.

•  When I manage the thoughts in my head, I can manage my whole body.

•   I’m avoiding things less and less. I’m making progress.

•   One step at a time – easy does it. Nothing succeeds like success.

First, what can we say to ourselves when we are preparing for something difficult? This helps you to re-evaluate the actual probability of the feared negative event happening – following trauma, most people overestimate the likelihood of danger. Second, what can we say as we approach and enter the difficult situation? This will help to reduce the desire to avoid and run away (which will only make it more difficult next time). The third stage is dealing with the feelings of anxiety and distress as they arise (to prevent them from becoming overwhelming), and the final stage is when looking back on the episode. Several examples of things you could try saying to yourself are provided in the box above.

Read the examples carefully and work out a few self-statements that you feel comfortable with. Then write them on a card that you can carry with you so that it’s handy when you need it. When you know you are about to do something difficult, it’s a good idea to set aside some time to prepare specific cards for the occasion. For example, if you are going into the city, you may write something like this on a small card that you can carry with you:

It’s natural to be nervous about going into the city given my traumatic experiences, but the likelihood of anything bad happening is very remote. Just relax and slow down my breathing. I may not feel great, but I can cope. Now, what is it that I need to do?

Like everything else, the more you practice using these self-statements, the more effective they will be in helping you to manage your anxiety at difficult times. This will become especially important as we move on to the next stage of treatment.

Changing behaviors

As we noted above, one feature of Posttraumatic stress disorder is that people lose interest in normal activities and withdraw into themselves, cutting off from friends and things they used to enjoy. This is a particular difficulty if you are not working. It is important to address this problem directly, even if you do not feel like it. Doing nothing provides lots of opportunities for the memories to come back and is a sure way of making you feel depressed and anxious.

When you get up in the morning (or the night before), make a plan of what you will do that day. Take a sheet of paper and write down the hours (say, from 9.00 a.m. to 9.00 p.m.) on the left-hand side. Then fill in each hour with what you intend to do. If you are working, that will take up much of the day. If not, you will need to try to find worthwhile activities to take up your time. Having some structure and routine to your day will do a great deal to help you feel more in control. Try to put in a broad range of activities but do not expect too much of yourself.

Possible activities for your daily timetable

•  Some exercise: walk, swim, cycle ride, gym

•  Some work: jobs around the house, study, chores, voluntary work

•  Something for fun: a movie, museum, art gallery, zoo, window shopping

•  Some social activities: visit friends, meet someone for coffee, a club or society

•  Some anxiety-management practice: relaxation, breathing, self-statements

•  Some time for other therapy homework

Arousal and anger

The strategies above are important in helping you deal with anger as well as anxiety. Anger often acts as a stumbling block to recovery, preventing you from moving on to the next stage of treatment. The physical aspects of tension and high arousal are similar in both anxiety and anger, but the triggers that set off the feelings will often be different. Try to identify the kinds of situation that lead you to become angry – the first step in managing your anger is being prepared for it. Take a sheet of paper and jot down a list of things that are likely to set you off. A major difficulty with anger is that it escalates so quickly that it becomes very hard to control. If you can recognize the warning signs and intervene early, you will have a much better chance of doing something about it. Think back to the last time that you were angry and jot down a list of the first signs that appeared. (What happened to you physically? What happened to your thoughts? What happened to your behavior?). Once you are more aware of the triggers and the early warning signs, you will be in a much better position to use the strategies described above to control your anger.

We will briefly look at three extra strategies that people find useful for dealing with anger in Posttraumatic stress disorder. They are all common sense, but can be very effective:

•  Delay: As we said, anger escalates very quickly so you need to find a way to stop yourself making that first angry response. Take a few slow, easy breaths and count to 10 before you react.

•   Time Out: If you feel the anger beginning to escalate, try to remove yourself from the situation. This does not mean storming out in a rage. It means explaining to the person you are with that you are not thinking too clearly and that you need a 5-minute break. Go outside or into another room and use some of the strategies described above to calm down. Then go back and try again.

•  Planning: Once you have identified the triggers, it is important to use that information to prepare yourself for high-risk situations. If you are going to do something that you know is likely to make you angry, choose a good moment (e.g., no other distractions, not too tired or hungry, plenty of time). Practice what you will do or say in your head beforehand.

Not surprisingly, anxiety frequently causes people to stay away from frightening situations. It is quite normal for people to want to escape or avoid situations, thoughts, memories, or feelings that are painful or distressing. However, this is one of the major impediments to recovery. Avoidance and escape provide temporary relief – the anxiety reduces – but the next time the person encounters that situation again, he or she is likely to become anxious long before it is planned to occur. We call this “anticipatory anxiety”. The more the situation is avoided, the more the person continues to believe that it is dangerous. Further, even if the person does not avoid, the anxiety may continue to build once they are in the situation. Very often people believe that if they do not leave the situation they will “lose control”, “go crazy”, “have a heart attack”, or have some other dire consequences. At the very least, they are likely to believe that the unpleasant feelings will be intolerable. Exposure therapy aims to show that this is not the case by helping the person to confront the feared situation. The important thing to remember when you are confronting something that you are frightened of (whether it is a situation or a memory) is that the anxiety will come down if you stay there long enough. There is no answer to the question of how long is enough. In some cases, the anxiety may drop considerably in 15 to 20 minutes. In other cases, it may take as long as an hour or more but it will reduce eventually. It is vital that you try to stay in the feared situation long enough for the anxiety to reduce. It is important to note also that anxiety often increases before it starts to drop. This temporary increase is often enough to make people avoid or escape – it is vital that you stay with the feared situation through this phase until the anxiety reduces. This pattern is shown in the figure overleaf. You will notice that the drop in anxiety is not smooth – you may notice occasional small increases – but the general trend is downwards. Exposure is done in a controlled and gradual fashion so that discomfort is kept manageable. By building upon repeated successes in facing these feared situations, you will eventually be able to confront them without anxiety and no longer avoid them.

In many ways, this approach is common sense. Let’s take an example of a little boy who is standing on the beach when a big wave knocks him over. He becomes very frightened of the sea and refuses to go to the beach the next day. How would his mother or father help? In order to overcome the fear, his parents may take him for a walk along the beach, staying away from the sea, holding his hand and reassuring him. Gradually, they walk closer and closer to the water’s edge. Eventually, the boy is able to go into the sea again unaided. This is a simple example, but exactly the same process applies to treating more severe and complex fears in adults.

This section discusses confronting activities, places, people, or objects that you have become frightened of since the trauma. We call this type of exposure “in vivo”. In vivo simply means “in real life”. When we are confronting memories, we have to do it in imagination, so we call it imaginal exposure – which is discussed in the next section. In conducting exposure treatment, your therapist will work with you in constructing a hierarchy – a list of feared situations in order of difficulty. Treatment involves tackling each item, one at a time, and moving on to the next only when you are confident to do so. More difficult items may be broken up into several steps. Exposure treatment can be difficult and painful, but it is the most effective way of treating many anxieties.

Planning your program

1.  Draw up a list of goals that you would like to achieve. These are likely to comprise places and activities that you have avoided since the trauma. The goals should be very specific and should vary from relatively easy to extremely difficult. Don’t worry if the worst ones seem unachievable at the moment – they will become easier as you progress through the others. List them in order of difficulty, starting with the easiest. For example:

•  To be able to go shopping at the local shopping center

•  To be able to catch public transport into the city

•  To go back to where the trauma occurred

As a general rule, as you work through the list you should be aiming to confront situations that produce a Subjective units of distress level of around 70. For the first one or two, however, we suggest that you start with ones that are a little easier than that (say, around 50) – it is important that you experience some success early on in the process.

2.  If something is too hard to try in one go, break it down into smaller steps. For example, if you were assaulted in a particular park, the first step maybe to go to the end of the street and look at the park from a distance. The second may be to go to the edge of the park, the third to walk into the park a short distance, and the final one to go back to the spot where the assault occurred.

3.  You may want to work on more than one item at any one time, but do not overwhelm yourself. When you have mastered one (i.e., you are able to do it with minimal anxiety), move on to the next more difficult one.

Implementing your program

1.  Try to do at least one of your selected goals every day. Avoiding something one day will set you back, as you will have built up the fear you are trying to reduce. Sometimes you will have bad days and feel that you are not progressing. It is important to still do something, although you may choose just to go over steps that you have already mastered.

2.  You will need to do each step several times until you master it. Once you can do it without too much anxiety, it is still important to do it once in a while to make sure you don’t slip back. The general rule is: the more you fear it, the more frequently you need to confront it.

3.  Keep a careful record of your progress. Take a sheet of paper and divide it into columns. In the first, write down your goal. In the second, note the date. In the third and fourth, write the time you started and (when you get back) the time you finished. In the fifth, write down the maximum Subjective units of distress you reached and in the sixth the Subjective units of distress level when you left the situation. The final column should be used for making any comments about the exercise. This will help both you and your therapist keep track of your exposure progress.

Practicing the steps

1.  Try to relax using the techniques described above before you start. Get yourself as calm as possible.

2.  Mentally rehearse the activity. Go through it in your mind and work out strategies to deal with difficult aspects. Practice the coping self-statements that you will say to yourself when you become distressed. Good preparation will make success more likely.

3.  Go about the exercise in a slow and relaxed manner – give yourself plenty of time.

4.  Keep an eye on your Subjective units of distress throughout the exercise. If they become very high (80 or more) before you’ve reached your goal, stop and wait for a while until the anxiety comes down a bit. When you feel ready, move on again slowly.

5.  Try to stay in the situation until you feel yourself calming down. Ideally, the Subjective units of distress should reduce by half (e.g., from 70 to 35). The longer you remain in the situation, the calmer you will become and the faster you will overcome your fears.

6.  Never leave the situation while your anxiety is still high. Try to face the fear, accept it, let it fade away, and then either move on or return. If you leave while the anxiety is still high it will be more difficult next time. Remind yourself that you have done really well to get this far; just hang in there until the anxiety comes down.

7.  Congratulate yourself for your achievements. This is very hard work and you deserve a pat on the back. Don’t put yourself down by saying that you could do this kind of thing easily before the trauma or that anyone should be able to do it without getting upset. It’s a vital part of your recovery.

What is imaginal exposure?

There are many analogies used to explain this process to Posttraumatic stress disorder sufferers before treatment commences. The following examples from our clinical practice may help you to understand what will happen and why it is important.

After a trauma, we often try to file away our memory of what happened, putting it to the back of our mind. It’s as if we are trying to pack the event away into a box. We then use a little strength to keep the lid tightly closed and try to leave it undisturbed. However, over time, two things happen. Firstly, our strength begins to wane and it becomes more of an effort to keep it sealed (that is, to stop the memories from coming back). Secondly, due to the pressure, the box begins to lose its shape and small cracks begin to appear. What we experience as symptoms (such as memories of the trauma, and having nightmares and disturbed sleep) is like the content of the box spilling out through these cracks. This is usually very frightening, so we try to avoid anything that reminds us of the trauma. We try to stop thinking and talking about what happened and how we felt. In this way, the content of the box becomes a “ghost” which we have learned to fear and which we are terrified of confronting. As part of therapy, we are going to open the box and inspect the content for what it really is. We will talk through what happened and how you felt. We will be inspecting the “ghosts” that have been created and throwing away any maladaptive and distressing beliefs you may have about the event. We find that once the trauma has been dealt with in this manner the symptoms become much less severe and less frequent.

Another analogy talks about the dentist:

When dentists work on a decayed tooth, they don’t just slap the filling on top of the decay. If they did, it might be fine for a few weeks or months, but the problems would keep coming back as the tooth continued to deteriorate. Instead, they spend some time drilling and scraping, cleaning out all the decay before putting the tooth back together. This is a very unpleasant and painful process, but we know it is worth going through this short-term pain for the long-term gain. Traumatic memories are a bit like tooth decay. We need to make sure that we have confronted all aspects of the trauma before we try to put the event behind us. We need to give ourselves time to face up to even the worst parts of the experience so that there are no skeletons in the closet to come and haunt us in the future. Like the dentist’s drilling, it is a painful process but an important part of recovery.

A final analogy comes from the work of Edna Foa, one of the leading experts in the treatment of Posttraumatic stress disorder:

Suppose you have eaten a very large and heavy meal that you are unable to digest. This is an uncomfortable feeling. But when you have digested the food, you feel a great sense of relief.

Flashbacks, nightmares, and troublesome thoughts continue to occur because the traumatic event has not been adequately digested. Treatment will help you to start digesting your heavy memories so that they will stop interfering with your daily life.

Exposure-based treatments are not for everybody. In some cases, if the trauma occurred many years ago and the memories are not causing too much of a problem, it may be best not to drag everything up again. Talk to your therapist about whether this approach would be beneficial for you.

Therapist-assisted imaginal exposure

Confronting the traumatic memories is a very difficult and painful process, and is best done with the help of an experienced therapist. There are several steps that your therapist will take you through. First, the therapist will provide an explanation of the process, including what you will be doing, why you are doing it, and a reminder on the SUD scale, as well as answering any questions you may have. Next, the therapist will work with you to develop a hierarchy of painful memories in much the same way as you developed a list of goals for your in vivo exposure above. If you have experienced several traumatic events, this may be simple enough. You will need to think about each event and rank them in order of how distressing they are for you to remember. If you have only experienced one event that is causing you problems, you will not need to generate a hierarchy.

The therapist will then ask you to go through the selected event or experience in great detail, starting at the beginning and continuing through to the end, to a point where you felt relatively safe. In order to keep the distress manageable, you may initially be allowed to keep your eyes open, to talk in the past tense (e.g., “I was walking along the path when I saw him coming towards me”), and to skip some of the worst details. For the procedure to be fully effective, however, you will need to build up (perhaps over several sessions) to making your account as vivid and detailed as possible. You will need to talk through the whole event with your eyes closed and in the present tense (e.g., “I am walking along the path and I can see him coming towards me”), since this makes it much more real for you. You will need to be careful that you do not miss any of the details, even (or perhaps especially) the worst ones. Remember that we do not want to leave any skeletons in the closet to come out and worry you in the future. Your therapist will repeat this process many times in the same session and/or in subsequent sessions. However, the more often you go through it the quicker you will recover, so your therapist may tape the session and ask you to listen to the tape every day at home. Again, this is not an easy process, but sticking to the following steps will help you through it and help to ensure that it provides the maximum benefit.

•   Step 1: Preparation.

•  Plan an activity to do immediately afterwards (e.g., go for a walk, visit or ring a friend; do an enjoyable absorbing activity, not an addictive activity like watching TV or drinking, or an emotional shutdown like hiding away on your own).

•  Choose a private place with no interruptions (take the phone off the hook, let others know you are not to be disturbed).

•  Identify two people you can contact immediately if you need help: keep their phone numbers handy.

•  Briefly relax yourself and try to clear your mind of other thoughts and worries: note down your Subjective units of distress level on a piece of paper.

•   Step 2: Confront the memory safely.

•  Listen to the tape and try to focus on what is being said: try not to imagine other, more frightening parts – just concentrate on the tape.

•  Equally, try to imagine it happening as if you were experiencing it again. What can you see, hear, smell, touch, taste? What are you feeling and thinking?

•  When reminded to do so on the tape, note your Subjective units of distress level. If it is above 90, take a moment to remind yourself where you are; you are safe here and now; you can feel as upset as you need to in the memory.

•  Don’t stop the tape in the middle: stick with the memory through to the end.

•   Step 3: At the end of the tape, pause and open your eyes.

•  Look around, feel the chair, remind yourself where you are and that you are safe.

•  Note your Subjective units of distress level and use an arousal management strategy if necessary (such as breathing control or relaxation).

•   Step 4: Process the memory by writing down some or all of:

•  What new (or old) pieces of the memory did you discover or became clearer?

•  Are you now thinking differently about any aspects?

•  What feelings or thoughts are going through your mind right now?

•  What parts of the memory are still too upsetting to remember or accept?

•  What do you still want to change about the event or its aftermath? How can you achieve that?

•  What did you do that you should be able to feel good about?

•   Step 5: Relax and do your planned activity.

Self-directed imaginal exposure

Many people find it difficult to do imaginal exposure to traumatic memories on their own. The process is too painful and they need the support and structure provided by a therapist. However, it is not impossible. Indeed, many people who recover from trauma without professional help are doing just that. They are thinking about the trauma often enough, for long enough, and in enough detail for the memory to lose the worst of its associated distress and for it to become modified and “sorted out” in their own mind. If you are going to attempt the process without a therapist, writing down the memory is often a useful way of doing it. (Indeed, it may be helpful to do this even if you are working with a therapist, although we suggest that you discuss it with him or her first.)

The assignment described below is adapted from the work of two American psychologists, Patricia Resick and Monica SchnickeMake sure you read through those steps carefully and prepare yourself properly before attempting the assignment. Select a suitable time and place so that you have enough privacy and sufficient time to do the task properly.

This task is important in helping you to sort out exactly what happened. The process of “putting the pieces of the jigsaw puzzle together” seems to be very important in getting over the incident. It also works in a similar way to the imaginal exposure described above – the more you confront the painful memories and the bad feelings associated with them, the less powerful and distressing they will become.

The task is to take a sheet of paper – an exercise book would be ideal – and write out a detailed account of exactly what happened. (Interestingly, research suggests that it is much more effective if you write it out by hand rather than using a word processor.) Include as many sensory details as possible (sights, sounds, smells, and so on). Also try to include all the thoughts and feelings that you had during the event. Do not stop yourself from feeling the emotions – although it is painful, that is part of the recovery process. If you become too distressed, you can stop writing for a while but try to continue again as soon as possible. It is important to keep writing until you reach the end (and a point of relative safety), even if that takes a long while. Make a note of your Subjective units of distress level in the margin every few minutes – this is important to compare your levels when you reread or rewrite the account. You can rewrite the account as often as you like, putting in more details or different perspectives as they come to you. On days when you do not rewrite the account, read it to yourself at least once. Again, stick to the steps outlined above when you do this. If you have kept a note of the Subjective units of distress levels in the margin, you will notice them dropping over time as you repeat the process. You will need to repeat the task until your Subjective units of distress are reasonably low throughout (say, a maximum of about 30).

Exposure: can I cope with it?

Exposure is a very difficult and painful process, but it is the only way to recovery. As we noted above, it is usually not as difficult as you fear it will be and most people get an enormous sense of achievement when they have confronted the memory or other feared situation. If you have read (and practiced) the sections above, you now have several strategies that will help you to manage your anxiety and distress. These are very useful to use both before and after the exposure exercises. If necessary, you can use them during the exposure exercises also, although we recommend that you do this only if you really need to. It is better to confront the full anxiety and allow it to reduce of its own accord than it is to use other strategies to bring it down. However, it is important that you do not feel overwhelmed at any time. Despite the best of intentions (in terms of preparing your hierarchies and confronting only situations or memories that you feel ready for) the anxiety will, sometimes, be greater than you expect. On those occasions, by all means use your coping strategies if necessary.

This program will aim to teach you to manage your worry and anxiety by learning to change the way you think and the way you react to your thinking and other events. In essence you will be learning new methods of control.

It is important to realize that achieving control of worry and anxiety is a skill that has to be learnt. To be effective, the skill must be practiced regularly and you will need to take responsibility for change. The more you put into the program, the more you will get out of it. It is not the severity of your anxiety, or how long you have been anxious, or how old you are that predicts the success of this program, but rather it is your motivation to change your reactions.

What is generalized anxiety disorder?

Generalized anxiety disorder is characterized by persistent feelings of anxiety and worry. The worry is typically out of proportion to the actual circumstances, exists through most areas of a person’s day-to-day life, and is experienced as difficult to control. The anxiety and worry are described as generalized, as the content of the worry can cover a number of different events or circumstances, and the physical symptoms of anxiety are not specific and are part of a normal response to threat.

Individuals with generalized anxiety disorder describe themselves as sensitive by nature and their tendency to worry has usually existed since childhood or early adolescence.

The symptoms of anxiety typically experienced by individuals with generalized anxiety disorder are:

•  Feeling restless, keyed up, or on edge

•  Being easily tired

•  Having difficulty concentrating, or having your mind going blank

•  Feeling irritable

•  Having tense, tight or sore muscles

•  Having difficulty sleeping; either difficulty falling or staying asleep, or restless unsatisfying sleep

Generalized anxiety disorder is one of the more common anxiety disorders in the community. A recent Australian survey has suggested that, in a 12-month period, 3 in 100 people will have a generalized anxiety disorder.

Generalized anxiety disorder and everyday worry

Everybody worries or gets anxious at some time in their lives. The worry in generalized anxiety disorder is identical in nature to that experienced by anybody else, but it tends to be out of proportion, pervasive, and difficult to control, unlike the worry most people experience. Hence it significantly interferes with an individual’s functioning. The constant anxiety-provoking thinking and the accompanying physical symptoms of anxiety can be disabling, particularly if experienced over a long period of time.

Another feature of generalized anxiety disorder is that it has usually been present for much of an individual’s life. From time to time, people may become unusually stressed, because of a physical illness or a life event such as divorce, bereavement, or loss (or threat of loss) of employment. During these times people may worry and become significantly more anxious, but after the stress resolves, the person can usually return to their usual functioning. This is not generalized anxiety disorder, but a temporary period of difficulty adjusting to stress.

Medication

You may be taking medication to help you cope with anxiety. If you are taking medication, you may need to talk about the issues discussed below with your therapist.

Antidepressant medication

Many of the medications that are useful to treat a depressive disorder are also useful in helping to control anxiety. If your doctor has prescribed you this type of medication, particularly if you have been depressed, it is important that you continue to take the medication for several months, and stop taking it only in consultation with your doctor. This medication typically has few side-effects, it is safe, and will not cause you to build up tolerance or become dependent.

When you are ready to stop this medication (usually after you have been feeling calm and in control for a number of months), it is very unlikely that you will experience a relapse of your anxiety if you have been able to learn and put into practice the strategies taught on this program.

Sedatives, tranquilizers, and sleeping pills

This class of medication is the benzodiazepines. They can block the feelings of anxiety very effectively, but also produce the following problems:

•  They can interfere with thinking and your ability to remember new information.

•  They can make you feel drowsy and sleepy.

•  They can interfere with your natural sleep cycle and rhythms.

•  They can produce tolerance, so that you might need bigger and bigger doses for the same effect.

•  They can produce dependence, so that you come to rely on them and experience an increase in anxiety without them.

•  They can produce withdrawal symptoms when you stop or cut down, producing unpleasant anxiety-like feelings.

•  They can make it easier for you not to use the strategies taught in this program. If you are taking this type of medication you would already have been asked to cut down gradually, with the aim of stopping completely. If you are experiencing any difficulties with this process, please discuss it with your therapist, who can then work with your doctor in achieving the goal of successfully stopping the medication.

The nature of anxiety and worry

The nature of anxiety

Anxiety is a normal and healthy reaction. It describes a series of changes in the body, and in the way we think and behave, that enable us to deal with threat or danger; changes that can be very useful if you have to respond very quickly.

Consider the following: You are crossing a wide and busy road at a pedestrian crossing. You suddenly notice a truck that has failed to slow down and will probably not stop, and it is heading in your direction. You start running for the safety of the sidewalk some meters away. The brain becomes aware of danger. Automatically, hormones are released and the involuntary nervous system sends signals to various parts of the body to produce the changes listed below.

•  The mind becomes alert.

•  Blood clotting ability increases, preparing for possible injury.

•  Heart rate speeds up and blood pressure rises.

•  Sweating increases to help to cool the body.

•  Blood is diverted to the muscles, which tense, ready for action.

•  Digestion slows down.

•  Saliva production decreases, causing a dry mouth.

•  Breathing rate speeds up. Nostrils and air passages in lungs open wider to get in air more quickly.

•  Liver releases sugar to provide quick energy.

•  Sphincter muscles contract to close the openings of the bowel and bladder.

•  Immune responses decrease, which is useful in the short term to allow massive response to immediate threat, but can become harmful over a long period.

And so you are able to run very quickly to the side of the road and escape being knocked down by the truck.

As you can see, this series of reactions, known as the “fight or flight” response, account for the many and varied feelings you can experience when you are anxious. In your mind you feel fear and apprehension; you are “on edge”, “keyed up”, and worried.

In your body, you may experience one or a number of the following sensations:

•  Trembling or shaking

•  Restlessness

•  Muscle tension

•  Sweating

•  Shortness of breath

•  Pounding or racing heart

•  Cold and clammy hands

•  Fast breathing

•  Dry mouth

•  Hot flushes or chills

•  Feeling sick or nauseated

•  “Butterflies” in the stomach

This fight or flight response is useful in the short term, especially if the danger can be dealt with by physical exertion. But it is of no use in the long term and certainly of little use in most stressful situations today – it does not help to run when the traffic cop pulls you over and it doesn’t help to fight physically when you are threatened by the boss. However, because the fight or flight response was useful when, in the distant past we regularly had to deal with physical danger, it remains part of our physical make-up. It is no wonder that when we are threatened, we can’t get enough air, our hearts pound, we feel nauseated, and our arms and legs tremble and shake, as all these responses would be useful if we could flee or fight.

The anxiety cycle

All of these changes in the body can be quickly reversed once vigorous physical activity has been carried out. This explains why many people report the desire to run or in some other way expend physical energy when placed in stressful situations. However, we are not often able to immediately engage in physical activity and therefore are less able to reverse the changes. For people who are prone to worry excessively, these changes can be quite disturbing and a new source of threat. This, of course, leads to further activation of the “fight or flight” response and the whole cycle is continued.

Anxiety and performance

Anxiety can become a problem if it occurs in situations where there is no real danger. The only part of the fight or flight response that is of use today when handling most stresses is the increase in mental alertness that it provides. It is very important to understand that, while increased awareness can be helpful, anxiety in some situations can be unnecessary or inappropriate.

Anxiety helps you to perform any skilled activity. If you are totally relaxed when you take an exam, play a sport, or discuss a problem with your colleagues, you will not give of your best. To do anything really well you need to be alert, anxious to do well, or “psyched-up”, in present-day terms. Anxiety in moderation is a drive that can work well to make you more efficient.

People with anxiety disorders often become afraid of the healthy anxiety that aids performance – they fear it might become uncontrollable and hence avoid using anxiety in this healthy way. Thus they limit their ability to give of their best.

This reaction is understandable, for if you don’t know how to control anxiety, it is probably better to have too little than too much. When people do get too anxious, their skill at problem solving, managing children, or meeting deadlines at work declines rapidly. Extreme anxiety interferes with the ability to think clearly and act sensibly. This, as everyone knows, is the sort of anxiety that robs us of our capacity to do things as well as we are able. In fact, the more difficult the task, the more important it is to manage anxiety carefully; ideally, one should be mildly anxious, alert, tense, and in control, for maximum efficiency.

The relationship between anxiety and skill is shown in the diagram. It is, therefore, important to learn strategies for remaining calm when appropriate, and alert, tense, and in control in difficult situations.

Chronic anxiety

If individuals find it difficult to break the anxiety cycle, the problems can become chronic. It is very likely that individuals with generalized anxiety disorder have had longstanding difficulties with managing anxiety, sometimes for months or even years. Some of the results of feeling anxious over a long time include:

•   Feeling restless or keyed up or on edge

•   Being easily tired

•   Difficulty concentrating or mind going blank

•   Irritability

•  Muscle tension

•  Trouble falling or staying asleep

•   Restless unsatisfying sleep

•   Feeling overwhelmed or unable to cope

•   Feeling depressed or demoralized

When you experience these problems, the anxiety has begun to interfere with your everyday life. Because anxiety is a normal, in-built, and at times useful response, you will never banish it completely from your life, but the good news is that you can learn to manage and control it.

Why do the symptoms of tension and anxiety begin?

The reason why you have become anxious is probably due to a combination of causes. We will briefly consider some possible causes.

The effect of personality

Personality refers to the usual way we react, feel, and behave year in and year out. Most people who seek treatment for an anxiety disorder have come to regard themselves as nervous, not just because of their high levels of anxiety, but because they consider themselves to be people who are usually sensitive, emotional, and worry easily. There are advantages to being like this, for the sensitivity means you can understand other people quickly and hence are often liked in return. It also probably means that you like to do things properly and treat other people well. But the emotionality and the proneness to worry are the seeds from which anxiety can grow.

The various strategies that we will teach you will aid you to control this aspect of your personality. If you do become upset and worry easily, then you’ll need to become particularly expert in remaining alert, tense, but in control to prevent you becoming too anxious in the face of difficulties.

The effect of life events and stressors

Anxiety may begin at a time when you are experiencing a high level of stress. Throughout our lives, we are constantly adjusting to demands placed upon us by changing circumstances. Making an important decision, meeting a deadline, changing jobs or routines, dealing with others in our lives all require constant adjustments. However, at times you may experience a single major problem, or several smaller problems, that may exceed your normal powers of adaptation. When high levels of stress occur, anxiety can result if they produce in you a sense of threat and lack of control.

The effect of your view of the world

Individuals with generalized anxiety disorder have an increased tendency – compared to individuals without an anxiety disorder – to automatically interpret information in their lives as threatening. For example, the ringing telephone is less likely to be considered with pleased anticipation of a friend ringing for a chat, but more likely to be viewed with alarm as news of an accident. Or a frown on the face of a supervisor at work is less likely to be viewed as the supervisor’s personal problem, but more likely to be viewed as a sign of disapproval. This view of the world is thought to develop from previous life experiences, which might include the impact of stressful life events, or the messages received from parents and other important people in your life.

The nature of worry

Worry is a central feature of generalized anxiety disorder. Most people can identify with the idea of “worry”, but scientists have defined the following features in the worry of individuals with generalized anxiety disorder:

•  It is usually a stream of thoughts or ideas.

•  It is accompanied by feelings of apprehension or anxiety.

•  It concerns future events and catastrophes.

•  It interferes with the ability to think clearly.

•  It is very difficult to control.

Research has shown that the typical person with generalized anxiety disorder can spend over half of their waking hours worrying. In most instances, the individual can recognize, with hindsight, that the worry was excessive and out of proportion to the actual event that triggered the worry.

A large number of worries tend to focus on day-to-day concerns, most typically:

•  Family and home life

•  Relationships

•  Work and study

•  Illness or injury

•  Finances

Common themes of worry in generalized anxiety disorder can include:

•  Problems arising in the future

•  Perfectionism and a fear of failure

•  Fear of being negatively evaluated by others

It is clear that individuals with generalized anxiety disorder worry largely about events that are remote (as opposed to in the immediate future) and which are unlikely to happen. This sort of worry is rarely helpful as it is unlikely to promote effective problem solving. For example, worrying that a relative might develop a life-threatening illness in the absence of any risk factors (a remote and unlikely event) will not affect the likelihood of it happening. However, adaptive worry might take place prior to an important exam if the worry led to a good problem-solving behavior – a time-table of study.

Worry about worry

A second level of worry has been identified in individuals with generalized anxiety disorder and includes thoughts such as:

•   “I can’t control my worry.”

•   “Worry is bad for me.”

•   “My worry will never end.”

•   “I will go mad with worry.”

These worries may increase the sense of threat and therefore symptoms of anxiety can rise even further.

Sometimes people come to believe that their worry might be useful. They might think:

•   “If I worry about the worst possible outcome I can be better prepared for the worst possible outcome.”

•   “Worrying about an outcome will stop it from happening.”

•   “If I stop worrying and something bad happens, I’d be responsible.”

•   “I can sort it out if I keep worrying about it.”

•   “I’d have nothing to think about if I didn’t worry.”

•   “My worry helps me to keep control of my anxiety.”

These beliefs are rarely confirmed, are rarely put to the test, and the individual continues to worry. If you hold any of these beliefs, it will be important to challenge them in order to be able to let go of the process of worry and its negative consequences. For example, if you did stop worrying about a particular event, would it really make it more likely to happen? But more about strategies to combat worry later.

Behaviors that can maintain worry and anxiety

A number of things you do to deal with the worry in the short-term may actually cause the anxiety and worry to continue in the longer term.

•  Reassurance seeking, or needing to check with others that things are going to be okay. For example, telephoning your partner frequently to make sure nothing bad has happened to them, or visiting your doctor any time you notice a sign or bodily sensation that might mean you are ill. Continually seeking reassurance from others might relieve the anxiety in the short term, but the relief is usually only temporary. Because you are never really allowed to deal with the initial worry yourself, you can come to depend on this reassurance, and unfortunately come to need it more and more to relieve anxiety.

•  Other forms of checking include obsessively reviewing the report for work or study to make sure that it is perfect, or not being able to take a break until all the tasks for the day are complete (and we all know how likely that goal is to be achieved!!). While there is not a lot of evidence that this type of checking ensures that work is perfect, or that everything gets done, the individual never learns that their work can be acceptable without the checking or that they can take breaks and still get things done. Instead, goals are set too high, and the individual becomes upset, anxious, and demoralized when he or she doesn’t achieve what has been planned.

•  Avoidance of situations or events that are thought to produce anxiety. For example, avoiding listening to the news because stories of disasters or illness will trigger worry about personal disaster or illness. Or avoiding people because of what they might say to you. Or avoiding any situation in which the chances of danger have been overestimated. Avoidance can seriously limit your life and the possibility of enjoying a range of activities that are so much a part of everybody’s life. When avoidance is based on an overestimation of danger, it is unnecessary and the belief of danger is never discontinued.

•  Procrastination, a special form of avoidance, which involves not beginning a task because of the anxiety associated with a possible negative outcome. Many times tasks are started only when the negative consequences of not starting outweigh the negative consequences associated with completing the task – some tasks never get started at all! For example, consider a dressmaker who can never start on special orders because of her fear that her client would not like the finished product and therefore think less of her both professionally and personally. In most cases, the feared consequences are overly negative, usually catastrophic, and not based on reality.

•  Another form of avoidance is trying to suppress or control worry. Unfortunately, the worry might well be made stronger by attempts to suppress it, possibly just because you are purposefully focusing your attention on it. Some research has suggested that the process of deliberately suppressing thoughts can cause them to intrude into your mind more forcefully when the thoughts are no longer being actively suppressed. This process has been called a rebound effect. Alternative strategies for dealing with worry that do not maintain the anxiety and worry are covered in later sections of the Manual.

Keeping a record of your anxiety or worry

Identification of the thoughts, feelings and behaviors that contribute to anxiety is an important part of the program. This information will help you and your therapist to plan the best strategies to manage problems with generalized anxiety.

Monitoring progress also allows us to see what works well and what doesn’t work so well, and so the plan can be adapted on that basis. The monitoring will also make sure that you are aware of the progress you are making, even if in small steps.

In particular we will be asking you to:

•  Identify the content of your worry.

•  Identify the beliefs you hold about worry (“worry about worry”).

•  Identify behaviors that may be maintaining your worry.

Each time you have an episode of anxiety or worry we will be getting you to complete a “Record of worrying thoughts” listed at the end of this section. Using the information in these records we will be able to identify:

•  Situations or circumstances that trigger worry or anxiety.

•  The situations that you avoid because of anxiety or worry.

•  Behaviors in response to your worry.

Relaxation Strategies:Generalized Anxiety Disorder

Thinking Strategies

Managing Worry

Structured Problem Solving

Dealing with behaviors that maintain anxiety or worry

When anxiety occurs for the first time with a certain situation, most people believe that, should they confront that same situation again, they would be more than likely to become anxious. Likewise, certain activities or problems may also have become associated over time with discomfort or anxiety. The occurrence of anxiety is unpleasant and so, as any sensible person would, sufferers soon learn to try to anticipate the situations or events likely to trigger their anxiety.

Of course, it is quite helpful to behave in a way to minimize objective danger, such as getting your doctor to check an unusual mole on your arm or avoiding deserted parts of the city late at night. On these occasions the anxiety that causes us to act in these ways will serve a useful purpose. The problem is that when they are anxious, individuals with generalized anxiety will often avoid situations that are not dangerous, such as upsetting TV or newspaper stories, meeting certain people, or anything that might remind them of their fears or worries. Others will put off doing things that they know should be done, or avoid solving their problems. Yet others will unnecessarily seek reassurance from those around them to decrease their fears or doubts.

The problem with these behaviors is that the relief is only temporary.

In practice, the things we avoid become harder and harder to do, and gradually we avoid more and more things. The need to seek reassurance becomes greater, and more and more reassurance is required to relieve the anxiety.

When anxiety is relieved by something we do, the fear can be made even worse, because the feeling of relief and drop in anxiety following the behavior tell us that the behavior was sensible. Thus, the behavior is reinforced or strengthened; after all, if you can avoid anxiety by acting in a particular way, why not do so? Unfortunately, you just identify more and more situations as difficult and avoid them also.

Then what is the cure? If avoiding the things you fear makes them harder and harder to face, what would happen if you started to confront your fears? If the fear is reinforced by seeking reassurance, what would happen if you prevented yourself from checking? Actually, if you confronted your fears or doubts for long enough, it would eventually go, and the fear the next time you encountered that situation would be less. However, most people don’t like to put this to the test, so they keep avoiding those situations or seeking reassurance.

One good way to break behaviors is to start with easy situations and slowly build up enough confidence to face the harder things. The other important strategy is to control the level of the anxiety using the breathing exercise and controlling worrying thoughts, and then stay with the situation until you have become more calm.

But how do you organize such experiences? First, you need to identify all behaviors that might be maintaining anxiety.

You have already made a list of:

•  Situations or circumstance that trigger worry or anxiety.

•  The situations that you avoid because of anxiety or worry.

•  Behaviors you engage in response to your worry.

Make sure that you include things that might not be obvious at first, such as certain topics of conversation or news items, missed opportunities, uncertainty, thoughts of illness or accidents, not accepting invitations, putting things off, or cutting activities short.

Then you plan ways of changing the behavior so that it no longer prevents you from facing what you fear. Some examples are listed below:

Avoiding newspaper items about life-threatening illness. Being unable to leave work until all correspondence is checked. Putting off your tax until a few days before the deadline.

Next, rank those situations or circumstances in terms of the anxiety that they cause, or would potentially cause. If the anxiety is too high to allow you to directly change that behavior then:

1.  You can break down the behavior into smaller, more manageable steps.

2.  You might need to address unrealistic worries about the outcome of this change in behavior.

Keeping your practice going

Some people have difficulty keeping up practice of their anxiety-management skills. This difficulty may be because they don’t think that they are making any progress, even though other people may see a change. Progress is often slow, and sometimes difficult to notice over a number of days. Take care not to underrate your achievements. Learn to praise yourself for your efforts in attempting new ways to deal with difficult situations, as well as your successes. Remember that praising yourself is an important factor in maintaining motivation, particularly in the early stages following treatment.

Dealing with setbacks

Setbacks can occur occasionally, even in persons who are making excellent progress. When this happens, people often become alarmed and despondent, fearing they have gone back to their very worst. Remember, no matter how badly you feel during a setback, it is very rare for you to go all the way back to your worst level of incapacitation. Also, day-to-day fluctuations in anxiety levels are bound to occur in the period after your treatment, just as in general day-to-day life. It is also important to remember that at these times it may be more difficult to think realistically about situations, and you may find some of your old worries (or some new ones) creeping back into your thinking.

For most people the apparent setback is only a passing phase, due to external factors such as extra work demands, the flu, or school holidays. In such cases, the setback is often viewed as devastating because it has a great deal of emotional meaning for the person who has put considerable effort into gaining control over anxiety. But this effort is not wasted and, after the stressful time passes, you can learn from this experience and again will find you are able to deal with anxiety. We often see this pattern. It is common, however, for people to worry that they will relapse as a result of encountering setbacks.

Expect to lapse occasionally

A lapse might mean that you start to engage in old unhelpful worries again. This is very different from experiencing a full relapse of your disorder. A relapse would involve a return to levels of symptoms you experienced before treatment and not use any of the techniques you have learned.

So the trick is to not turn a lapse into a relapse and exaggerate the lapse into being bigger than it really is. Most people will have some sort of lapse when they are trying to change their behavior. If you have noticed that you have slipped in your use of the anxiety-management skills, don’t say things to yourself such as:

“I’m really hopeless. I’m right back where I started from. I’ll never be able to change.”

Instead, you can view your lapse in the following light:

“I’m disappointed that I have let things slip, but I can deal with that and I’m not going to turn it into an excuse for giving up altogether. Now, I’ll get out my Manual and start my practice again.”

Therefore, if you have a setback don’t add to the problem with all the old catastrophic and unhelpful ideas. Keep practicing all the techniques you have been taught and you will still be making progress.

Of course, many people do stop things like relaxation when they have been feeling okay for some time. This is fine, so long as you keep aware of any stress or anxiety that may be creeping back into your life, and restart the exercises as soon as you become aware of any increase. It will also be important to reinstate such techniques if you have recently experienced any stress or life event.

It may also be helpful to revisit some of the thinking strategies you found useful over treatment. For example, rather than trying to deal with unhelpful worries in your mind, write them down! You will remember that this helps you to distance yourself from your fears and to be more realistic in your thinking.

Long-lasting change

People with longstanding anxiety have usually suffered for a long time. Most often, anxiety problems will begin in adolescence, but most individuals do not reach treatment until their late 20s or 30s.

In this program, our aim is that you will not only change your reactions and your ability to cope with adversity, but also change the way in which you have learned to think. Such ways of thinking may have become an intrinsic feature of your personality, perhaps even that part of yourself that you consider makes up what is “you”. However, this feature turns you into your own worst enemy. In effect, you will eventually need to change the unhelpful aspects of the way you think and behave. You will need to do this in order to make your life more rewarding, to make you more effective and efficient in your work, and to help you to become closer to the people around you.

These changes will not be easy, because changing a fundamental part of the way you think and behave is not easy. But with continued and solid practice of the new skills you have learned, you will continue to make positive changes over future months and even years. Before you realize what has happened, you will find yourself saying:

“I used to get upset about that, but now I don’t!”

Relaxation is the voluntary letting go of tension. This tension can be physical tension in the muscles or it can be mental, or psychological, tension. When we physically relax, the impulses arising in the various nerves in the muscles change the nature of the signals that are sent to the brain. This change brings about a general feeling of calm, both physically and mentally. Muscle relaxation has a widespread effect on the nervous system and therefore should be seen as a physical treatment, as well as a psychological one.  You will need to be an active participant in relaxation, committed to daily practice for 2 months or longer.

Importance of relaxation training

Part of the fight or flight response involves the activation of muscle tension, which helps us to perform many tasks in a more alert and efficient manner. In normal circumstances, the muscles do not remain at a high level of tension all the time but become activated and deactivated according to a person’s needs. Thus a person may show fluctuating patterns of tension and relaxation over a single day, according to the demands of the day, but this person would not be considered to be suffering from tension.

When people have been anxious for long periods of time or when people have not taken time off from work or other activities, they seldom allow the muscle tension levels to become deactivated, and the tension tends to stay with them for longer and longer periods. Eventually, these people cannot recognize tension or are unable to relax the tension away. The tension no longer helps them to perform their daily tasks, and may even hinder normal activities. Because of the tension, these people may feel jumpy, irritable, or apprehensive. This may be why many people often report feeling slightly unwell much of the time, with headaches or backaches, or they feel slightly apprehensive all the time, worrying about things unnecessarily. Constant tension can make people oversensitive and they respond to smaller and smaller events as though they were threatening. By learning to relax, it becomes easier to gain control over these feelings of anxiety.

Since some tension may be good for you, it is important to learn to discriminate when tension is useful and when it is unnecessary. Actually, much everyday tension is unnecessary. Only a few muscles are involved in maintaining normal posture, e.g., sitting, standing, or walking. Most people use more tension than is necessary to perform these activities. Occasionally, an increase in tension is extremely beneficial. For example, it is usually helpful to tense up when you are about to receive a serve in a tennis game. Likewise, it is probably helpful to tense up a bit before a job interview. This tension keeps you keen and alert. Do not become frightened of this type of tension. The tension is unnecessary when:

•  It performs no useful alerting function.

•  It is too high for the activity involved.

•  It remains high after the activating situation has passed.

What physical changes occur during the relaxation response?

•  The mind becomes more tranquil.

•   Hormone production decreases.

•   Breathing rate decreases as less oxygen is needed.

•   Heart rate decreases and blood pressure drops.

•  Sweating decreases markedly.

•  Muscles relax.

Note that these responses are opposite to the “fight or flight” response.

Components of relaxation training

In order to be more in control of your anxiety, emotions, and general physical well-being, it is important to be able to relax. To do this you need to:

•  Recognize tension.

•  Relax your body in a general, total sense.

•  Let tension go in specific muscles.

Recognizing tension

When people have been tense and anxious for long periods, they are frequently not aware of how tense they are, even while at home. Being tense has become normal to them and may even feel relaxed compared with the times they feel extremely anxious. However, a high level of background tension is undesirable, because worry or other anxiety symptoms can easily be triggered by small increases in arousal brought on by even trivial events. Consider the following:

•  Where do you feel tension?

•  Do you notice tension in your face and jaw?

•  Do you clench your fists?

•  What other parts of your body feel tense?

•  Are there parts of your body where tension goes unnoticed until you feel pain?

•  What are the characteristics of the tension?

•  Do the muscles feel stretched and sore?

•  Do the muscles feel hard and contracted?

•  Do the muscles feel tired?

•  Does there appear to be effort involved in maintaining normal posture?

•  Which events lead to an increase in tension?

•  Anger?

•  Worry?

•  The way people speak to you?

•  Having to wait in lines or at traffic lights?

•  Being watched while working?

•  Your relationships?

Relax your body in a general, total sense: achieving the relaxation response

Progressive muscle relaxation means that the muscles are relaxed in a progressive manner, usually starting with the hands and arms and ending with the leg muscles. Relaxation exercises should be done at least once a day to begin with, preferably before any activity that might prove difficult. Initially, do the exercises in a quiet room, free from interruption, so that you can give your entire concentration to relaxation. Explaining the exercises to those you live with will generally lessen any embarrassment and aid in cooperation in minimizing interruptions. Select a comfortable chair with good support for your head and shoulders.

If a chair does not provide good support, use cushions placed against a wall. Some people prefer to do the exercises lying down, but do not use this position if you are likely to fall asleep. These relaxation exercises are not meant to put you to sleep, since you cannot learn to relax while asleep. Sleep is not the same as relaxation – consider those times when you have awakened tense. If you do want some method to put you to sleep, go over the relaxation exercises in your mind or keep a relaxation tape specifically for that purpose. As you master the relaxation exercises, try inducing deep relaxation in various postures and situations.

It is usually not a good idea to practice progressive muscle relaxation while performing activities that require a high degree of alertness, e.g., driving a car or operating a machine. Instead, use one of the specific muscle exercises described further on.

When possible, it is advisable that you use the relaxation exercises as a preparation for some activity over which you anticipate difficulty. Decide which form of relaxation you will use, arrange your seating appropriately, finish all you need to do, and then start the exercises. It is important that you have nothing external to think about while you are relaxing. Therefore, if you are expecting a phone call, leave the phone off the hook; likewise, don’t start cooking just before relaxing if something might boil over. When you are relaxing, you can be comfortably aware that any distractions that occur are not important and don’t require your attention.

During the relaxation avoid tensing the muscles too tightly or they may become overly tense and then difficult to relax, or you may even cause cramping. About 60% to 70% of your maximum tension is usually recommended.

After you have finished the relaxation, don’t jump up right away. First, you might feel momentarily dizzy and misinterpret this normal reaction as a sign of some other problem. Second, you might get straight back into the old habit of tensing. Get up slowly and try to preserve the state of relaxation for as long as possible. Set about your activities in a slow and peaceful manner.

Remember, relaxation is a skill and, as such, improves with practice. Do not despair if you do not reach deep levels of relaxation during your early sessions. The more frequently you practice relaxation, the deeper the relaxation will be, and the longer lasting the effect.

You will need to commit yourself to at least 8 weeks of daily practice in order to achieve really long-lasting effects. Naturally, longer is even better. Some people continue daily relaxation many years after leaving treatment. If you can do this, we recommend it. However, not all people continue relaxation in this way. It is our experience that people who benefit most from relaxation either practice regularly or practice immediately when they notice any increase in tension or anxiety.

Let tension go in specific muscles: isometric relaxation

Isometric relaxation exercises can be done in everyday situations. Most exercises do not involve any obvious change in posture or movement. Others involve some movement and are best reserved for doing in some place where movement or stretching isn’t likely to draw too much attention.

In the early stages of training, you may have to do these exercises several times a day to counteract tension and maintain a relaxed state, particularly when anxious. As you improve, they will take less time and become easier. Eventually, you will find that you are doing them without thinking – i.e., they may well become a habit that you will use automatically to counter tension.

There are some important points that need to be remembered when you are doing the isometric exercises. You are asked to hold your breath for 7 seconds while you hold in tension, but some people occasionally find this too long. Don’t become obsessive about holding your breath – try to hold it for 7 seconds if you can but this is not crucial. The most important thing is to concentrate on putting the tension in slowly over approximately 7 seconds and releasing the tension slowly over approximately 7 seconds. The most common mistake that people make with isometric exercises is putting the tension in too quickly or putting in too much tension. These are meant to be gentle and slow exercises. The aim of the exercise is to relax you, not to get you even more tense. If circumstances do not allow you to hold the tension for 7 seconds, you can still benefit from putting in the tension slowly over some period of time and releasing it in the same manner.

Some example exercises

When sitting or lying down in private:

•  Take a small breath and hold it for up to 7 seconds.

•  At the same time, straighten arms and legs out in front of you and stiffen all muscles in the body.

•  After 7 seconds, breathe out and slowly say the word “relax” to yourself.

•  Let all the tension go from your muscles.

•  For the next minute, each time you breathe out say the word “relax” to yourself and let all the tension flow out of your muscles.

Repeat if necessary until you feel relaxed. When sitting in a public place:

•  Take a small breath and hold it for up to 7 seconds.

•  At the same time, slowly tense leg muscles by crossing your feet at the ankles and press down with the upper leg while trying to lift the lower leg.

Or

•  Pull the legs sideways in opposite directions while keeping them locked together at the ankles.

•  After 7 seconds, breathe out and slowly say the word “relax” to yourself.

•  Let all the tension go from your muscles.

•  For the next minute, each time you breathe out say the word “relax” to yourself and let all the tension flow out of your muscles.

Shoulders and neck:

•  Hunch shoulders up towards the head.

•  Let shoulders drop and let arms hang loose

Important points about learning to relax quickly

•  Relaxing is a skill – it improves with frequent and regular practice.

•  Do the exercises immediately whenever you notice yourself becoming tense.

•  Develop the habit of reacting to tension by relaxing.

•  It helps to slowly tense and relax the muscles.

•  When circumstances prevent you from holding the tension for 7 seconds, shorter periods will still help but you may have to repeat the exercise a few more times.

•  Do not tense your muscles to the point of discomfort or hold the tension for longer than 7 seconds.

•  Each of these exercises can be adapted to help in problem settings, such as working at a desk or waiting in a line. Use them whenever you need to relax.

•  Using these exercises, you should in a few weeks be able to reduce tension and prevent yourself from becoming overly tense.

Difficulties with relaxation

Some people report that they cannot relax or that they cannot bring themselves to practice relaxation. Since all human beings share a similar biological make-up, there is usually no purely physical reason why relaxation should work for some people and not others. The reason that relaxation may not work for some people is usually due to some psychological factor or insufficient practice. I am too tense to relax: In this case, the individual uses the very symptom that needs treating as an excuse for not relaxing. Relaxation may take longer than expected, but there is no reason why someone should have to remain tense. I don’t like the feelings of relaxation: About 1 in 10 people report that, when they relax, they come into contact with feelings that they don’t like or feelings that frighten them. These feelings indicate that you are coming into contact with your body again and noticing sensations that may have been kept under check for many years. You do not have to worry about losing control during relaxation sessions. You can always let a little tension back in until you get used to the sensations. I feel guilty wasting so much time: Relaxation is an important part of your recovery. Many therapies take time, e.g., physiotherapy. You do not have to be openly productive to be doing something useful. I can’t find the place or time: Be adaptive. If you can’t find 20 minutes, find 10 minutes somewhere in the day to relax. If you do not have a private room at work, go to a park. Relax during the evening, while your partner is reading the newspaper – you do not have to be alone to relax. Don’t choose a time when you would rather be elsewhere. For example, don’t choose to relax at lunchtime if you would prefer to be with friends. I’m not getting anything out of this: Unfortunately, many people expect too much too soon from relaxation training. You cannot expect to undo years of habitual tensing in a few relaxation sessions. Impatience is one of the symptoms of anxiety, so you need to understand that this reaction is a sign that you actually need to continue with relaxation training. Give the training time to take effect. Set long-term goals, rather than monitor your improvement day by day. I haven’t got the self-control: You need to realize that quick, easy cures for longstanding tension that call for no effort from you do not exist. The longest-lasting treatment effects occur when an individual takes responsibility for his or her recovery and commits to daily practice of a relaxation strategy.

A Situation, Event or Interaction

Noticing a mistake in a report you have written for work

Сemotional Response and Behavior

Anxiety, annoyance; hiding from the boss

This presumption is important because it may lead people to believe that they have no influence over the way they think, feel or behave. But thoughts intervene between A and C, so the true association is:

A Situation, Event or Interaction

Noticing a mistake in a report you have written for work

Вrhoughts or Beliefs

“I must be really stupid. The boss will be really annoyed. I’ll lose my job.”

Cemotional Response and Behavior

Anxiety, annoyance; hiding from the boss

Another important point is that different people will often have very different thoughts, and therefore very different reactions, in response to the same event. Consider the following example. Three people are waiting at a bus stop. They see the bus approach, hail the bus – and it just drives past without stopping.

•  The first person gets angry and clenches their fists.

•  The second person gets anxious and their heart starts to pound.

•  The third person shrugs their shoulders and gets on with reading the newspaper. The same event produced three different responses, because it is not the event that directly produced the feelings and behavior, but rather the thoughts the three people had about the event.

•  The first person might have thought, “That driver should have stopped! Now I’m going to be late for an important meeting!”.

•  The second person might have thought “I’m going to be late, I’ll never get everything done in time, and the rest of the day will be a disaster!”.

•  The third might have thought “I might be late, but there’s not much I can do about it right now”.

So people can respond differently to the same situation. Their emotional response and behavior (C) is related to the way they think about or interpret (B) any given situation or event (A).

If you are like the first or second person in the example above you might tend to see things as worse than they need be, and you may be causing yourself unnecessary anxiety. All people who have suffered anxiety for many years develop habitual and unhelpful ways of thinking about situations. They often tend to expect the worst; often so much so that they bring the “worst” on. The way an individual reacts to events and to people is largely tied into the expectations and assumptions that that individual holds about particular situations and their self. Some of these expectations and assumptions may not be particularly helpful.

Expectations such as:

•  “I know that something dreadful is going to happen.”

•  “I can’t concentrate and it’s affecting my whole life.”

•  “I’ll always be anxious.”

•  “My worry will drive me crazy.”

•  “Everyone will see that I’m not coping.” … are likely to increase anxiety.

Typically, these expectations and assumptions have been built up over a number of years, so much so that they at times seem automatic. They do, however, have significant implications for how upset you feel and how you actually behave.

It is important to recognize that unhelpful thinking patterns are habits, and that habits can be changed with effort and practice. Identifying unhelpful thoughts associated with anxiety is the first step in changing your thinking.

Identifying anxiety-provoking thoughts

In any situation or interaction in which you find yourself unhappy with your feelings or actions, ask yourself:

•  What do I think might happen?

•  What do I think about myself?

•  What do I think about the other person?

•  What do I think about the situation?

•  How do I think I might cope?

•  What will I do?

Individuals with generalized anxiety are often preoccupied with worries, ruminations, and catastrophic thoughts. This “doom and gloom” type of thinking is centered on anticipated consequences (what might happen) or unreasonable self-expectations.

Hence individuals will often predict the worst outcome, overestimating the chance that it will happen: “I’m not going to have enough time to prepare properly.” “It’ll be wrong.” “I’ll fail the test.” “I’ll develop a fatal illness.” or may underestimate their own ability to cope: “I’m just not good enough to succeed at this.” “I’ll just fall apart.” In some cases, the personal consequences of an event will be greatly exaggerated: “It will be a disaster if this doesn’t work out right.” “I’ll never get another job.”

“I’ll be a social outcast.”

The thinking behind much anxiety is usually based on an extreme statement of what might happen rather than a realistic appraisal of what probably will happen. People are capable of taking a potentially unpleasant event and making it worse than it has to be by dwelling upon it, and by thinking in intricate detail of all the things that could potentially go wrong. If you have come to think about certain events or situations as dangerous or awful, then indeed you will be upset in direct response to your interpretation of “dangerous” or “awful”.

You quite obviously don’t do this deliberately, but over the years you may have developed patterns of thinking about the situations that upset you that are unhelpful and have become largely automatic. For example, the physical sensations of anxiety can be very frightening. Someone who is worried that their anxiety symptoms may really be signs of an underlying and yet unrecognized serious physical illness would be said to be responding reasonably to their label, or interpretation, of their experiences. They believe the symptoms to be dangerous, even though they are objectively harmless. The problem is that the label applied is wrong! Worrying that one may be ill will cause more anxiety, and bring on even more of the unpleasant bodily feelings that caused the worry in the first place.

Once you have been able to identify what you have been saying to yourself, determine whether it was helpful in the situation. The following guide should help. Helpful thoughts are generally:

Challenging anxiety-provoking thinking

Identifying and challenging your unhelpful automatic thoughts is not always that easy. To give you some extra help, there are four types of question that you can ask yourself that may make the unhelpful aspects of the thoughts more clear.

•  What is the evidence for what I thought?

•  What alternatives are there to what I thought?

•  What is the effect of thinking the way I do?

•  What thinking errors am I making?

What is the evidence for what I thought?

Ask yourself if the thought would be accepted as correct by other people. From your or other people’s experience, what is the evidence that what you believe is true? Ask yourself if you are jumping to conclusions by basing what you think on poor evidence. How do you know what you think is right?

As well as engaging in a mental exercise of weighing the evidence, you can actively go out and seek evidence for and against the belief.

Examples of anxiety-provoking thoughts could include:

1.  “If I’m anxious, they’ll think I’m stupid and never want to talk to me again.”

2.  “Worrying it through might stop the worst from happening.”

3.  “If I were to slow down for even one minute, I’d never achieve anything.” Each of the above thoughts may be unrealistic. If you had these thoughts, you could argue with yourself about their truth. However, the best test would be to see:

1.  If people still spoke to you after you were anxious when you went out with them.

2.  If the feared event happened if you stopped worrying about it.

3.  Whether or not you still got things done if you did slow down. In weighing up the evidence, ask yourself:

•  How likely is what I fear to happen?

•  What is the worst thing that will realistically happen?

•  How bad would that be, really?

What alternatives are there to what I thought?

Is the thought the only possible one that you could have? Perhaps there are alternative interpretations of an event or ways of thinking about something. What might someone else say about the situation. Determine whether any of these alternative views have better evidence for them or would be more helpful in managing your feelings.

For example, you feel uncomfortable when talking to someone on whom you’d like to make a good impression. You notice yourself stammer slightly and are acutely aware of silences. You might think “They must think I’m acting weird, they’ll see I’m weak and anxious and won’t want to know me.”

But how do you know?

They might be thinking

“She (he) seems a bit tense today, I hope nothing’s the matter…”

“… maybe they’re not feeling well.”

“I wonder whether they’d like to see a movie tonight.”

“Will I have enough time to get to the shops on the way home?”

What is the effect of thinking the way I do?

Another way of disputing your thoughts is to ask yourself what are the advantages and disadvantages of thinking that way. If you can think of an equally valid way of thinking that brings more advantages, why choose the one that brings disadvantages?

Perfectionism, or having to get it right all the time, is a common theme of worry in generalized anxiety disorder.

What thinking errors am I making?

Some examples of common thinking errors include:

Thinking in all-or-nothing terms: This is black-and-white thinking in which things are seen as all good or all bad, either safe or dangerous – there is no middle ground.

“I am totally hopeless if I am less than thoroughly competent or achieving in everything I do.” Using ultimatums: Beware of words like always, never, everyone, no-one, everything, or nothing. Ask yourself whether the situation really is as clear-cut as you are thinking.

“Things never go right for me. No-one else has problems like me.” Condemning yourself on the basis of a single event: Because there is one thing that you can’t do or have not done, you then label yourself a failure or worthless.

“I made a mistake today; I am a complete failure.” Concentrating on weaknesses and forgetting strengths: Try to think of other times you have attempted or even been successful at something and think about the resources that you really do have.

“My anxiety is taking so long to get over, I haven’t made any progress and that’s just typical of me.” Blaming yourself for what is not your fault: This will only make things worse, so think through the arguments for and against. If it is not your fault, stop blaming yourself (even if you cannot think of anyone or anything else to blame).

“I’m too weak to deal with my worry.” Taking things personally: Are you “personalizing” everything so that it has relevance to you or caused by you when in fact it has nothing to do with you?

“That woman in the magazine with cancer is the same age as me, I could get cancer.” Expecting perfection: People invariably make mistakes. Accepting imperfection does not mean accepting low standards but it means acknowledging mistakes and learning from them rather than being paralyzed by failure.

“It’s got to be exactly right, or it is not even worth starting.” Using double standards: Many people expect of themselves what they would not expect of others. Ask yourself, “How would I react if it was someone else in my situation? Would I be so hard on them?”

“I can’t possibly say that I disagree with them; they’d be annoyed and dislike me.” Overestimating the chances of disaster: Things will certainly go wrong and there is danger in the world, but are you overestimating these? How likely is it that what you expect will really happen?

“I might lose my way; my car will break down; I’ll be stranded, or bashed or raped.” Exaggerating the importance of events: Often we think that some event will be much more important than it turns out to be. Ask yourself, “What difference will it make in a week or 10 years? Will I still feel this way?”

“That fight we had yesterday has ruined everything.” Fretting about the way things ought to be: Telling yourself that things should be different or that you must act in a certain way indicates that you may be worrying about how things “ought” to be rather than dealing with them as they are.

“I must get rid of this worry. It’s not normal.” I can do nothing to change the situation: Pessimism about a lack of ability to change a situation leads to feelings of depression and lowered self-esteem.

There may be no solution, but you will not know until you try. Ask yourself whether you are really trying to find answers and solutions.

“I can’t help the way I think. I can’t change or control my feelings.” Predicting the future: Just because you acted a certain way in the past does not mean that you have to act that way forevermore. Predicting what you will do on the basis of past behavior means that you will cut yourself off from the possibility of change.

“I usually get anxious at parties, so I know I won’t enjoy the next one.”

Blaming the past: Just because certain things happened in the past doesn’t mean that significant changes cannot be made by you for the future. “My past is the cause of all my problems. It will continue to affect me and I will never change.”

Generating alternative thinking

Changing the way you think sounds easier than it is. Having identified the automatic and unhelpful thoughts that contribute to anxiety, you will need to learn to look at each of these thoughts objectively and then say what a realistic view of the situation is. This process is going to take time and effort on your part.

If your thinking pattern is well-learned and practiced until it becomes habitual, it can become difficult to shake. You will need to write down your worries and what you fear and then evaluate whether the fear is justified or whether it is an unrealistic view of a situation. The objective in learning how to change the way you think is not to try to convince yourself that things are better than they are; rather, the aim is to be able to recognize when your thinking is unhelpful.

Following are some examples of such unhelpful thinking, together with some alternatives for each of the situations involved.

Helpful thinking does not reject all negative thoughts; it is not simply wishful thinking. It involves looking at things in a way that is most realistic, given the facts. For example:

Unhelpful thinking

“I didn’t get the job, which proves that I am a failure. I’ll never get a job or have things go right for me.”

Helpful thinking

“I am disappointed I didn’t get that job, but I can cope.”

Wishful thinking

“Who cares! I didn’t want the job anyway.”

Unhelpful thinking

“What if I can’t cope with this? It will be absolutely disastrous.”

Helpful thinking

“I’m going to give this a try. I’ll give it my best shot and see how it goes.”

Wishful thinking

“It’ll be easy!”

All our thoughts do not necessarily have to be centered on disappointments, but it is often in such situations that you can feel anxious or hopeless. If things do not go as you would hope or if people do not behave as you would like, check whether your disappointment is reasonable. If so, face your disappointment, but do not make a catastrophe out of it!

Assumptions and core beliefs

While automatic thoughts are usually easy to recognize as verbal messages in your conscious mind, it may be important to learn to understand the assumptions or core beliefs that lie behind the thoughts.

Assumptions operate as rules that guide our daily actions and expectations, and are usually “If … then…” or “should” statements. Some examples of assumptions are “If I don’t get things right all the time then people will think that I am stupid” or “If I let other people see what I’m really like then they might not like me” or “Others mightn’t like you if you disagree with them”.

The deepest level of thinking is the core belief. Core beliefs are absolute statements about yourself, other people, or the world. Some examples of core beliefs are “I am stupid” or “Others will reject the real me” or “It is wrong to disagree”.

Many people would have held these assumptions and core beliefs since their childhood.

Record of attempts to change unhelpful thinking

Young children develop rules to make sense of their experiences (“dogs bite”, “dogs are friendly”) and to guide their behavior (“stay away from dogs”, “play with dogs”). Children also learn rules from the things others tell them and from observing the way others behave. These rules are not necessarily true and, in childhood, may not be very flexible (“all dogs bite”, “all dogs are friendly”). As people grow older they tend to be able to develop more flexible rules as they learn that everything is not black and white. However some beliefs may remain inflexible, even into adulthood, and will continue to dictate how you interpret and react across various situations. If the assumptions or core beliefs are unrealistic and unhelpful then they may lead to intense or long-lasting levels of anxiety or depression. Luckily, assumptions and core beliefs can be changed in much the same way as automatic thoughts.

•  Identify beliefs.

•  Look for repeated themes in your thought monitoring or diary.

•  Ask yourself “If that were true, what would it mean about me?”.

•  Test beliefs.

•  Gather evidence that the belief may not be 100% true.

•  Critically examine your beliefs and their effect on your feelings and behavior.

•  Consider the advantages and disadvantages of holding the belief.

•  Allow more time for change in assumptions and beliefs than in automatic thoughts.

•  Record evidence that a belief may not be 100% true all of the time.

•  Identify alternative helpful beliefs.

Through the program, you will be asked to write down your thinking for each situation or circumstance where you find yourself anxious or worrying. Use the “Record of attempts to change unhelpful thinking”.

Excessive worry or ruminating about events that are unlikely to happen can make you feel worse than you need to and may even increase feelings that you cannot cope. It may feel as though by worrying about things you might be able to anticipate and avoid future catastrophes, but in reality the worry does not lead to productive or constructive action. Instead, problems remain unsolved, fears are not confronted, and the unhelpful beliefs about events or situations continue unchallenged. In the following sections more practical steps for helping to deal with worry are described.

Problem solving

Determine whether there is a real problem that requires solving. Ask yourself:

•  Is the feared event likely to happen?

•  Is it imminent?

•  Is there anything you can do about it?

If you answer yes, deal with the problem using an efficient problem-solving strategy. For example, you might be in a situation where you need to find a new job, move house, or put up an unexpected and unwelcome house guest. Rather than worry about how you will cope, you can short-circuit the worry by planning how to solve the problem – then make sure the plan is put into action!

Indecision

Determine whether the worry is driven by indecision. Many individuals with generalized anxiety disorder are anxious that they might do something wrong or make the wrong decision. They may be overly perfectionistic. The anxiety may cause these individuals to procrastinate or continually put off making a decision, or they may deliberately continue to “worry through” the decision in an attempt to ensure that they don’t make a mistake. For example, people may find themselves going through a lengthy series of questions and answers about major life decisions such as “Am I in the right job?”, “Am I in the right relationship?”. Or there may be a series of day-to-day decisions that cause worry, such as “Should I go to that party?” “What present should I buy my partner?” or “Which task should I start first?”

Unfortunately this “worrying it through” process does not usually help to find the “right” decision (as there may not be such a thing as the “right” or “wrong” answer) but instead increases and extends feelings of anxiety and uncertainty, thereby feeding the indecision. Furthermore, this process may cause you to come up with a wider range of catastrophic consequences that you would otherwise have come up with. In other words, the more you worry, the more and more negative you may become.

Sometimes people will not want to make a decision until they believe they have all the information relevant to that decision. For example, every travel agent will need to be contacted to check out every deal before the holiday can be booked, or every consequence has to be thought out before a plan embarked upon. Unfortunately it is rarely necessary to have this level of certainty before making a decision, and impossible to be free from any doubt. If your worry is driven by indecision:

•  Determine whether there is any unhelpful thinking that lies behind your worry. For example, “Is there really a ‘right’ answer to your decision?” “Realistically, what would really happen if you made a decision one way or the other?” “What’s the worst that could happen?” “What evidence is there that you are unable to make a decision?”

•  If there is a decision to be made, set a reasonable amount of time to reach a decision, and then act on iti .

•  Then make sure that you don’t engage in any further worry about the decision.

Worry about worry

A number of examples of worry about worry can be challenged using the strategies covered in the previous section.

Worry is really bad for my health.

Worry will drive me mad.

I can’t control my worry.

I will worry like this for the rest of my life.

Ask yourself:

•  “What is the effect of thinking this way?”

•  “What is the evidence to support these beliefs?”

•  “What alternative explanations might there be?”

•  “What is more likely based on past experience?”

For example, if you worry that you will be unable to control your worry, ask yourself what typically happens when you do worry. Are you really never able to stop it? What eventually stops the worry? So next time, how likely is it that the worry will go on and on forever? What do you think would happen if you tried to postpone the worry by telling yourself that you will give yourself time to think about it later in the day? Why don’t you try this and see what happens? What would happen if you deliberately tried to lose control through worry?

Positive beliefs about worry can be challenged using similar strategies. For example, ask yourself when worrying about the worst possible outcome has actually helped you to cope with the outcome? It is likely that the answer to this question would be that the worst possible outcome has never come about! Would you really be increasing the chances that a bad thing would happen by not worrying about it? Why don’t you stop worrying about it and see if it really happens?

Letting go of worries

Once you have reached the stage when you are able to effectively challenge catastrophic and unhelpful worries, and you are able to dismiss the notion that worry might be helpful, it is time to stop the worry process itself. In order to do this, you will need to say: “It may never happen I just don’t need to think about it!”

It may be helpful to think of times when you have not been troubled by worry and rumination. Probably during these times you were involved intently in an activity that you enjoyed a lot or that took up all of your attention. It is very difficult to think properly about more than one thing at the same time.

Thus it is sometimes useful to have a strategy to draw your attention away from worrying thoughts – once you have decided that it is appropriate not to continue to think about them. You have probably already noticed that it is extremely difficult to stop such thoughts just by trying to push them out of your mind. A better solution is to acknowledge the worry, and then focus your attention on something else. For example, “That’s a worry. It’s not worth my thinking about it. I’ll get on with my work.” “I can’t determine exactly what will happen in the future, I will focus on what I’d like to do today.”

If stuck, here are some examples of things to do:

•   Concentrate on what is happening around you: Get involved in the moment. Choose something that is likely to interest you and engage your attention. Give yourself a specific task: listen carefully to the conversation; begin the next task at work; make that telephone call.

•  Engage in some form of mental activity: Read a magazine or book; complete a crossword puzzle; watch a movie.

•  Engage in some form of physical activity: Do some exercise; wash the car; take the dog for a walk.

Structured problem solving is a useful strategy for anyone with problems, whether those problems are related to anxiety, or other personal matters, such as dealing with a difficult colleague at work. The approach can also be used by groups of people, such as families, friends, and workmates. For example, your family may be facing financial difficulties and may need to cut expenses, or they may have a problem in that nobody is prepared to do the dishes in the evening. Problem solving can also be applied to achieving goals, such as getting a job, planning a social activity, or improving one’s fitness.

There are no perfect or ideal solutions to problems, but the structured problem-solving approach aims to lead you to the most effective plan for action.

Setting up a problem-solving session

Because this structured approach is best suited to problems that are difficult, serious, or capable of causing anxiety and worry, problem solving should occur only in certain settings and at times specifically set aside for that purpose. For instance, do not try to do problem solving while watching TV or cooking the dinner. There should be no competing jobs or distractions: take the phone off the hook, or, if you have young children, plan to hold your problem-solving session after they have gone to bed.

Do not attempt to solve more than two problems in the one sitting. It is useful to plan an agenda in advance. In this way, you will more likely avoid unrelated worries or ruminations that will interfere with the problem-solving process. It is often useful to write down all of your problem-solving exercises. Writing things down will often put problems and solutions into better perspective and ensure that a record of the decisions you make is always available.

Identifying problems

Most people will have no difficulty in recognizing where their problems lie, but to help you in this task, the following points may be helpful:

•  Use your feelings as a cue for recognizing problems. Rather than viewing your feelings as the problem, consider what may be causing the way you feel. If you have interpreted the circumstances correctly, then the event itself may be a problem that needs to be addressed, changed, or resolved.

•  Use your behavior as a cue for recognizing problems. If you continue to make mistakes, or things don’t work out as you would like, the situation itself may be the problem and you may be able to manage it more effectively.

•  Consider the content of your worries. Is there a problem that requires solving behind these worries?

Step 1: Defining problems and goals

A clear definition of a problem or goal is the next step in problem solving. Goals should be realistic and fairly easy to attain. Defining problems or goals helps to focus thinking on the issue at hand and minimize the possibility of getting sidetracked onto other issues. Also, it makes it easier to know when the goal has been achieved or the problem solved.

At this stage of problem solving, there are some “rules” that will make the definition of a suitable goal or problem more likely.

•  Do not get sidetracked into attempting to solve the problem at this stage. This attempt will not help to define the problem and may only lead to increased worry or anxiety.

•  Be specific. The more specific the goal or problem, the easier it will be to solve. For example, avoid vague statements along the lines of “I want to feel better”, or “My boss is inconsiderate”. Rather, redefine the problem in terms of the actual feelings or behaviors, such as “I want to reduce my headaches” or “I am unhappy about my boss expecting me to work on weekends without extra pay”.

•  Focus towards the future. Because problem solving aims to provide a plan to deal with present or future events, don’t focus on past occurrences of the problem or distant causes underlying the problem. For example, “I would like to go out to lunch with my work colleagues and feel comfortable”, is better than “I avoided lunching with my work colleagues last week because I was too anxious”.

•  Some difficult goals may need to be broken down into smaller goals that can be achieved more easily and in a shorter period of time. For example, if a goal involves finding a new job, the first step may be to decide what sort of job to look for.

Step 2: Generating solutions through brainstorming

Brainstorming is a method by which we come up with as many alternative solutions as possible. Rather than try to think of the best or ideal solution, we list any ideas that come into our minds, including those that we may think are not useful or even absurd. In fact, some of the proposed solutions should deliberately be absurd – use your imagination! Even though a solution may at first seem ridiculous, it may help to generate better solutions than those that are more obvious.

At this stage of problem solving, there is no discussion of the solutions. They are just listed.

Select a problem that you can work on and try to define it so that it is specific, concrete, and attainable. As an exercise in brainstorming, try to come up with as many possible solutions for this problem. Try also to think of a few ridiculous solutions.

Step 3: Evaluating the solutions

This step involves a brief discussion of the advantages and disadvantages of each solution. Do not write these down, just quickly run through the list of solutions, noting the strengths and weaknesses of each. No solution will be ideal, as every good idea will have some faults. However, most bad ideas will also have some advantages as well, e.g., they may be easy to apply and provide some short-term relief, but not really solve the problem in the longer run.

Briefly run through the solutions you generated to the problem above.

Step 4: Choosing the optimal solution

In this step, the aim is to choose the solution (or combination of solutions) that will solve the problem or achieve a goal.

It is often helpful to choose a solution that can be readily applied and not too difficult to implement, even though it may not be the ideal solution. At least, you can get started right away. The problem may not be solved immediately, but you might have made a difference, and what you learn by trying might be useful the second time around. This is preferable to choosing a solution that is doomed to failure because you have been overly ambitious.

Step 5: Planning

A detailed plan of action will increase the likelihood that the problem will be solved. Even if your solution is excellent, it will not be of any use if it isn’t put into practice. The most common reason why solutions fail is through a lack of planning. Be sure to spend some time on this planning stage.

The following checklist applies to any problem and is helpful to see whether you have planned properly.

•  Do you have the necessary resources available (time, skills, equipment, money) or are you able to arrange the necessary resources or help?

•  Do you have the agreement or cooperation of other people that might be involved in the plan?

•  Have all the steps been examined for possible difficulties?

•  Have any strategies been planned to cope with likely difficulties? Setting specified times or deadlines will minimize the risk of procrastination.

•  Have any strategies been planned to cope with any negative (or positive) consequences?

•  Have difficult parts of the plan been rehearsed, e.g., a telephone call, conversation, interview, or speech?

•  Has a time been set for a review of the overall progress of the plan?

Step 6: Review

Problem solving is a continuing process as problems are often not resolved or goals not attained after only one attempt. Because not every possible difficulty is considered at the planning stage, ongoing reviews are necessary to cope with unexpected set-backs. Steps may need to be changed or new ones added.

It will also be important to praise all efforts that have been made. If you reward yourself and others for the work that has been done, it is more likely that the successful process will be followed and that problems will be solved in the future.

When things don’t go as planned

•  What went right?

•  What went wrong?

•  What alternative strategies could be used?

•  Acknowledge feelings of disappointment, but do not allow any unhelpful thinking to turn the disappointment into a catastrophe. Difficulties are usually due to a poorly planned strategy rather than personal inadequacy. Everyone does as best they can.

•  Label any attempt as partial success rather than failure. Consider partial success as practice and a useful learning experience.

•  Try again as soon as possible.

Problem-solving practice

From now on, whenever you are faced with a difficulty or problem that appears difficult to resolve, use the following six-step method of structured problem solving. For many problems, there are no easy answers or ideal solutions, but at least you will know that you have tackled your problem in the most effective and efficient manner.

Structured problem solving

Step 1: What is the problem/goal?

Think about the problem/goal carefully, ask yourself questions.

Then write down exactly what the problem/goal is.

Step 2: List all possible solutions:

Put down all ideas, even bad ones. List the solutions without evaluation at this stage.

Step 3: Assess each possible solution: Quickly go down the list of possible solutions and assess the main advantages and disadvantages of each one. Step 4: Choose the “best” or most practical solution: Choose the solution that can be carried out most easily to solve (or to begin to solve) the problem.

Step 5: Plan how to carry out the best solution: List the resources needed and the major pitfalls to overcome. Practice difficult steps, make notes of information needed.

Step 6: Review progress and be pleased with any progress: Focus on achievement first. Identify what has been achieved, then what still needs to be achieved. Go through steps 1 to 6 again in the light of what has been achieved or learned.

This Manual is both a guide to treatment and a workbook for persons who suffer from obsessive-compulsive disorder. During treatment, it is a workbook in which individuals can record their own experience of their disorder, together with the additional advice for their particular case given by their clinician. After treatment has concluded, this Manual will serve as a self-help resource enabling those who have recovered, but who encounter further stressors or difficulties, to read the appropriate section and, by putting the content into action, stay well.

The nature of obsessive-compulsive disorder

Obsessive-compulsive disorder is an anxiety disorder that, until quite recently, was regarded as a rare condition. Recent studies have shown that Obsessive-compulsive disorder is considerably more common than was previously thought and as many as 2 in every 100 people may suffer from the condition.

Obsessive-compulsive disorder is characterized by persistent, intrusive, unwanted thoughts that the sufferer is unable to control. Such thoughts are often very distressing and result in discomfort. Many Obsessive-compulsive disorder sufferers also engage in rituals or compulsions that are persistent needs or urges to perform certain behaviors in order to reduce their anxiety or discomfort or to prevent some dreaded event from occurring. More often than not, the rituals are associated with an obsessional thought. For example, washing in order to avoid contamination follows thoughts about possible contamination. For some, there is no apparent connection between the intrusive thought and the behavior, e.g., not stepping on cracks in the sidewalk in order to avoid harm befalling one’s family. Others have no compulsive behaviors and suffer from obsessional thoughts alone, while still others do not experience obsessions but have compulsive rituals alone.

The one common element to the various symptoms in Obsessive-compulsive disorder is anxiety or discomfort. For those suffering both obsessional thoughts and compulsive rituals, it is the anxiety or discomfort associated with the thought that drives the ritual. In other words, the ritual is performed to reduce the anxiety produced by the thought. For those suffering from obsessional thoughts alone, anxiety is often associated with the thought, and mental rituals, distraction, or avoidance may be used to lessen the discomfort and ensure that the fearful event does not occur. It’s much the same for those with compulsive rituals alone in that the behavior is performed in order to lessen the urge to ritualize. The role of anxiety is important in Obsessive-compulsive disorder and will be discussed in much greater detail in subsequent sections.

Most Obsessive-compulsive disorder sufferers can see the uselessness and absurdity of their actions but still feel compelled to perform their various rituals. They know that their hands are not dirty or contaminated and they know that their house will not burn down if they leave the electric kettle switched on at the wall. Because they are aware of how irrational their behavior is, many sufferers are ashamed of their actions and go to great lengths to hide their symptoms from family, friends, and, unfortunately, even their doctors. It is extremely important that your therapist is aware of all of your symptoms no matter how embarrassing or shameful they may be, as this is the only way that a suitable treatment program can be designed for you. Rest assured that a therapist experienced in the treatment of Obsessive-compulsive disorder will have heard of symptoms worse than yours many times over.

Symptoms of obsessive-compulsive disorder

Obsessional thoughts are usually concerned with contamination, harm to self or others, disasters, blasphemy, violence, sex or other distressing topics. Although generally called thoughts they can quite often be images or scenes that enter the sufferer’s mind and cause distress. For example, one sufferer may have the thought “My hands are dirty” enter his head. This thought will trigger washing rituals. Another sufferer will actually have enter her head the scene of her house burning down. This scene will trigger checking rituals. Individuals who suffer obsessions alone may also experience thoughts, images, or scenes. For example, someone who has obsessions about harming his or her children may have the thought of harming them or have a frightening scene of hurting them or an image of the children already hurt.

As was pointed out earlier, many obsessions produce anxiety or discomfort that is relieved by performing rituals. The most common rituals are washing and checking, although there are many others, e.g., counting, arranging, or doing things such as dressing in a rigid, orderly fashion. Although rituals are performed to alleviate the anxiety or discomfort that is produced by the obsession, the anxiety relief is usually short lived. An individual who washes in order to avoid or overcome contamination will often find himself or herself washing repeatedly, because either he or she was uncertain whether a thorough enough job was done or because the obsessional thought of contamination has recurred. Similarly, someone who checks light switches, stoves, and so forth in order to avoid the house burning down, often has to repeat the behavior over and over, because he may not have done it properly or the thought or image of his house being destroyed has recurred. Even individuals who have obsessional thoughts alone may find that they have to repeat the cognitive rituals such as counting or praying many times over as they may not have done them perfectly in the first place.

An important point to keep in mind is that many sufferers have more than one type of symptom so that individuals may engage in more than one type of ritual or have more than one type of obsessional thought. Another point to note is that symptoms change over time and someone who is predominately a washer may, over time, develop checking rituals that eventually supersede the original complaint. In addition to changes in symptoms, the course of the disorder may also fluctuate over time, with periods of worsening and periods of improvement. Other sufferers may find that their symptoms remain static, while yet others may find a gradual worsening of symptoms since the onset of the disorder.

For many sufferers of Obsessive-compulsive disorder, these symptoms take up a great deal of time, often resulting in their being late for appointments and work and causing considerable disruption and interference with their lives. Apart from disrupting their own lives, it also frequently interferes with the lives of family members, as the typical sufferer often asks the other members to do things a certain way or not to engage in certain behaviors, as this may prompt the sufferer to engage in rituals. Thus the symptoms are controlling, frustrating, and irritating not only to the patients, but also to their families, friends, and workmates.

Avoidance of certain situations or objects that may trigger discomfort and rituals is also quite common among Obsessive-compulsive disorder sufferers. It seems logical to avoid contact with contaminants if you are a person who washes compulsively, or to avoid going out of the house if you must check all the electrical equipment, the doors, and windows. While this seems like a reasonable way of coping, it actually adds to the problem, as the typical sufferer avoids more and more situations and gradually the problem comes to rule their life. Moreover, avoidance does little to deal with the problem as it serves only to reinforce the idea that such situations are dangerous. Because the situation or object is constantly avoided, there is no opportunity for the individual to learn that there is no danger.

The causes and treatment of obsessive-compulsive disorder

At the time of writing, no one is certain of the causes of Obsessive-compulsive disorder. Though there are a number of theories that attempt to explain the development of the condition, in general there is little evidence to support any one of them exclusively. In fact, it may be best to consider Obsessive-compulsive disorder as a complex problem with complex causative factors. It is most likely that a combination of psychological, biological, environmental and other factors result in the development of the disorder. We do know that for some the onset is during childhood, while for others the onset may be during adolescence or early adulthood. We also know that in some cases the onset is sudden, while others have a slow, insidious onset. Some of the theories that have been proposed to explain the development of Obsessive-compulsive disorder follow and are for information purposes only.

The biochemical theory

This theory was put forward after it was found that certain medications were of benefit in the treatment of Obsessive-compulsive disorder. These drugs affect mainly one type of chemical in the brain, called serotonin. Consequently, it was hypothesized that a problem with serotonin could be the cause of Obsessive-compulsive disorder. Although the drugs are indeed effective in the treatment of this condition, there is little hard evidence to indicate that sufferers have a deficit of serotonin in their brains. As medications have become more specific and selective in their effects on Obsessive-compulsive disorder, there has not been any difference in outcome to those medications that did not have such specific effects.

The genetic theory

This theory was put forward to explain the finding that Obsessive-compulsive disorder can sometimes occur in families. Although a genetic predisposition may account for some sufferers developing the condition, there is also the possibility that the Obsessive-compulsive disorder behavior was learned from the parents or siblings. It is extremely difficult to differentiate between Obsessive-compulsive disorder behavior that may be the result of genetics or Obsessive-compulsive disorder behavior that may be the result of the environment. Nevertheless, emerging evidence tends to suggest that early or childhood onset Obsessive-compulsive disorder subjects are more likely to have close relatives with Obsessive-compulsive disorder than those who have a later onset. This, however, is by no means always the case as many childhood onset subjects have no relatives with Obsessive-compulsive disorder.

Learning theory

This model suggests that obsessive-compulsive behavior has been learned through a process of conditioning. Put simply, this theory states that a neutral event becomes associated with fear by being paired with something that provokes fear, anxiety, or discomfort. This fear then generalizes so that objects as well as thoughts and images also produce discomfort. The individual then engages in behaviors that reduce the anxiety and, because the behavior is successful in reducing anxiety, even if only for short periods of time, it is performed each time discomfort or anxiety is felt. The problem with this theory is that it fails to explain why particular fears such as those of contamination or of harm to oneself and others commonly occur in Obsessive-compulsive disorder. Another problem is that many sufferers do not recall any significant precipitating event that can explain the onset of their symptoms. However, this theory does explain how obsessive-compulsive symptoms are maintained, and, as a result, this issue will be dealt with in much greater detail in subsequent sections.

Cognitive theory

This theory is one of the more comprehensive theories put forward and suggests that intrusive thoughts are experienced by all people. Individuals with Obsessive-compulsive disorder, however, attach negative meanings to their intrusive thoughts or images and feel personally responsible for having the thoughts, as well as responsible for the possible outcome of the thoughts. For example, someone who has thoughts of harming a loved one may believe that they are a bad person for having such thoughts and that they should also be very careful to ensure that the thought of harm does not become a reality. They do so by ritualizing. What maintains the Obsessive-compulsive disorder is the meaning they attach to the thought as well as their responding to the thought through rituals or other attempts to neutralize the thought. Treatment focuses on challenging the beliefs about the thoughts as well as exposure and response prevention.

Psychoanalytical theory

This theory basically states that obsessive-compulsive symptoms are attempts to keep unconscious conflicts and impulses from conscious awareness. Unfortunately, there is little evidence to support this theory and psychoanalysis is of little value in the treatment of the majority of Obsessive-compulsive disorder sufferers.

As can be seen, no theory is able to adequately explain the development of Obsessive-compulsive disorder but that does not mean that there are no effective treatments. In fact, the cause, though of considerable interest, has little bearing on treatment outcome. It is important to note, however, that in some cases symptoms that resemble Obsessive-compulsive disorder may be the result of other illnesses such as depression and schizophrenia. Effective treatment of these conditions will generally result in a decrease in the Obsessive-compulsive disorder-like symptoms. Other conditions that may result in symptoms that resemble Obsessive-compulsive disorder are Tourette’s syndrome, dementia, brain trauma, or other neurological disorders.

The treatment of obsessive-compulsive disorder

There are currently two effective treatments available for Obsessive-compulsive disorder that may be used separately or together. One is drug treatment, with medication that increases the availability of serotonin in the brain; the other involves the use of behavior therapy techniques. At present, it appears that they are both effective and there is little in the scientific literature to suggest that combining the two results in a better outcome than using them individually. However, some sufferers who find behavior therapy too difficult initially may benefit from a course of medication so that effective behavior therapy can be undertaken.

Medication

The medications that have been found to be particularly helpful in the treatment of Obsessive-compulsive disorder come from the antidepressant family of drugs and include clomipramine, fluoxetine, fluvoxamine, and sertraline. They have specific effects on serotonin levels in the brain. Serotonin is the biochemical substance that some researchers believe is involved in Obsessive-compulsive disorder. In general, these medications have been shown to be effective for some Obsessive-compulsive disorder sufferers and assist them in bringing their symptoms under control. If one of these medications is prescribed for you, you should be made aware of possible side-effects and report their occurrence to your therapist. It is important to remember that these medications are not a cure for Obsessive-compulsive disorder. In addition, research indicates that ceasing the medication in the short term generally results in a return of symptoms. It could be that sufferers need to remain on the medication for long periods of time or that behavior therapy should be used in conjunction with the drug.

Behavior therapy

The rationale for using behavioral techniques is explained briefly under learning theory above but it is important enough to state again in greater detail. Typically, the Obsessive-compulsive disorder sufferer has intrusive thoughts that generate anxiety, discomfort, or an urge to carry out a ritual in order to lessen anxiety or prevent some dreaded event. Performing the ritual results in a decrease in anxiety or discomfort, and is actually reinforcing through its ability to reduce these negative feelings. For example, an individual has the thought that his or her hands may have touched something dirty or contaminated. This thought produces anxiety in that the person feels uncomfortable about the possibility of being contaminated or contaminating someone else. This unpleasant anxiety or discomfort is relieved by washing of the hands or other contaminated objects and it feels good to rid oneself of such negative feelings, so it feels “good” to wash. In the same manner, an individual who must check the stove and heaters prior to leaving home in order not to cause a disastrous fire will feel some relief after checking these items many times to ensure they are off. Thus the anxiety-producing thought is temporarily minimized by checking, and it feels “good” to check.

This anxiety- or discomfort-reducing quality that the rituals possess is shown in the following graph. Patients were asked to rate their levels of discomfort and urge to ritualize (1) before being exposed to an anxiety-provoking stimulus, (2) after being exposed, and (3) after performing their rituals. As can be seen, exposure to the stimulus results in a marked increase in discomfort and urge to ritualize.

Engaging in the ritual brings about an immediate and dramatic decrease in both these measures.

Though the decrease may be short lived, the individual very quickly learns that the discomfort may be reduced again by performing the ritual. The more anxious the individual feels, the more ritualizing they engage in. This is further worsened by their inability to concentrate on what they are doing to the extent that they are unsure that the ritual was conducted properly. This adds to their anxiety, which they try to bring under control by ritualizing further. For example, an individual who checks electrical equipment, doors, and windows prior to leaving home learns very quickly that checking alleviates the discomfort associated with the thought that the house may burn down or be broken into. The individual may have to perform the checking rituals a number of times in order to gain some relief. If he or she is under pressure from other sources and is preoccupied or distracted by these other worries, then they will have to engage in the rituals many more times because they may not have been done “correctly” the first few times. Having seen how compulsive rituals are maintained, the important question is what can be done to break the vicious cycle between the discomfort-producing thought and the anxiety-reducing rituals. Again, research into the condition provides the answer.

Exposure and response prevention

Investigators looking at the phenomenology of Obsessive-compulsive disorder examined what happened when sufferers were exposed to stimuli that triggered rituals and were asked not to engage in their rituals. Initially, there was a significant rise in anxiety, discomfort, and urge to ritualize. Rather than continue to get worse, however, this rise remained quite steady and then gradually decreased so that by the end of the session, the level of discomfort had almost returned to normal. When this process was repeated again and again, the surprising finding was that the initial discomfort and anxiety was less with each exposure and the time taken to return to normal was shortened so that eventually exposure to the stimulus would result in a “hiccup” in anxiety that would then quickly settle. The initial findings of this research are demonstrated in the following diagram.

These findings led to the development of the behavioral treatment known as exposure and response prevention. As the names suggest, the two elements of this treatment are:

•  Exposure to the cues or triggers of the compulsive rituals

•  Prevention of the ritualized response

Prevention does not mean that the person suffering from the condition is restrained or held back from performing the ritual but rather that the individual, with the help of the therapist, voluntarily does not engage in the ritual.

In repeating this process of exposure combined with response (ritual) prevention, the end result is one of perhaps mild discomfort when the sufferer is confronted with triggers for the rituals, but the most important change is that the individual is now in a position to control the problem rather than be controlled by it.

When sufferers are made aware of this form of treatment, the initial reaction is either one of disbelief that such simple methods may work or, alternatively, that it appears extremely difficult. First, this form of treatment is not as simple as it seems. The approach must be structured, planned, and systematic in order to have maximum benefit. The individual needs to be motivated and consistent in his or her efforts to overcome the problem and faithfully follow all homework and clinic assignments. Approaching the problem in a haphazard manner will invariably result in a less than optimal outcome, with sufferers feeling disappointed, frustrated, and hopeless. A consistent and planned approach ensures that the problem is dealt with in a systematic manner. Any difficulties encountered can be quickly dealt with by the patient with the assistance of the therapist. Second, for those who see this approach as too difficult, the fact that the treatment program is planned by you in conjunction with the therapist ensures that the pace is at a level you are capable of mastering and the various steps can be graded to maximize your chances of success.

Obsessional thoughts

The principles of exposure and response prevention are also applied to the treatment of obsessional thoughts and images, except that there are no obvious behavioral rituals to work on. This does not mean that someone who has intrusive thoughts does not engage in rituals to reduce anxiety and discomfort; it is just that the rituals may also be thoughts. If, for example, an individual with Obsessive-compulsive disorder experiences frequent blasphemous thoughts, he or she may attempt to reduce the discomfort by saying a short prayer to himself or herself. Similarly, individuals who have thoughts of harming their children will often deal with the anxiety that such a thought produces by trying to push it out of their heads or by desperately reassuring themselves that they love their children and would never harm them.

Other sufferers with obsessional thoughts alone often have more elaborate and definite rituals. For example, having to mentally retrace their steps to ensure that they did not harm anyone while driving to their destination, or having to remember whether anything sharp stuck into their body because they fear contracting AIDS, or having to say something a certain number of times in order to avoid some disaster. When the problem of obsessional thoughts is conceptualized in this way, the treatment for the condition is readily apparent and involves exposure to the anxiety-provoking thought while, at the same time, not engaging in cognitive or mental rituals to lessen the discomfort.

There are, however, some important differences in the treatment of obsessional thoughts, especially considering that exposure to thoughts is not as easy as exposure to concrete objects: treatment involves confronting the thought or image until it no longer causes the individual distress or discomfort. For those who suffer from obsessional thoughts, this may seem to be an impossible task, but when you consider that everyone experiences unpleasant, strange, or bizarre thoughts at some time, then the goal of treatment appears more realistic. The major difference between obsessionals and everyone else is the meaning they attach to their intrusive thoughts. An individual who does not suffer from Obsessive-compulsive disorder will experience an intrusive thought but will dismiss the thought as silly and it will be gone. If it does recur, then it is again regarded as silly and meaningless and dismissed. Someone suffering from Obsessive-compulsive disorder, however, may experience the same thought and will desperately try not to think about it or will try to think of something to negate or cancel the thought. In other words, they react with fear, dread, and anxiety, so that the chances of the thought recurring and causing further distress is greatly heightened. Attempts not to think about the thought is like trying not to think of a pink elephant, whereas attempts to negate it through mental rituals only serve to reinforce the thought’s apparent power. Put simply, it’s your fear of the thought and the meaning you attach to the thought that ensures its continued return and your continued distress. The object of treatment is to disengage the emotional meaning of the thought from the thought itself so that it becomes “just another thought”. This result is achieved through the exposure program, which should be designed to provide you with specific disconfirmations about the thoughts and their meanings. In cases where there are quite strong beliefs about the thoughts and their meaning, cognitive techniques aimed at challenging the beliefs about the intrusive thoughts may help to change your beliefs and assist you to more readily engage in exposure. It is important to discuss these techniques with your clinician. Exposure should not only involve the obsessional thoughts but also must include any situations that the individual has been avoiding because of the possibility that the thoughts may be elicited. For example, a sufferer who fears harming his or her children may avoid contact with knives or other sharp objects while the children are around, or someone with blasphemous thoughts may avoid going to church for fear of bringing on the thoughts while there. Avoidance of such situations needs to be overcome in order to maximize and maintain the gains made from treatment.

Basic rules for success

The first requirement for the success of this treatment is motivation. Overcoming Obsessive-compulsive disorder is difficult and requires persistent effort on the part of the sufferer. Obviously, there will be periods when treatment is going smoothly and others when the progress is slow and difficult. The important points to bear in mind are that the problems have been with you for a considerable period of time and are probably well ingrained in your daily routine. Overcoming these difficulties will most certainly take time and you should allow yourself as much time as it takes to get yourself better. You don’t need to add to your difficulties by being impatient. Second, progress is not in a straight line but tends to be fluctuating so that having occasional bad days is the rule rather than the exception. The two graphs below are to demonstrate the difference between what people expect to happen and what actually happens.

Most people expect the response to treatment to be linear, i.e. they start treatment and expect to get better and better. What actually happens, however, is that there are fluctuations from day to day, with some days being worse or better than others. When the fluctuations in the right-hand graph above are evened out (dotted line), it becomes obvious that the individual is improving, even though at times it may not feel as though they are getting better. They may even feel as though they are slipping back. It is important to reassure yourself that having a bad day does not mean that the situation is hopeless or that you are back to square one. In fact, the only individuals sure to return to square one are those who lose their motivation and no longer persist with the program.

Another basic requirement for a positive outcome is, for want of a better word, honesty. You need to be honest with yourself and your therapist in terms of your fears, avoidance, rituals, and thoughts. At times, individuals who know they have to be exposed to situations that they have avoided for long periods of time will avoid telling the therapist about similar situations or will not complete homework assignments. This does nothing to help the sufferer overcome the problem in any way. Telling yourself that the problem will be dealt with later is just another form of avoidance. It is important that you keep your therapist informed of your progress, difficulties, and fears at all times so that, if need be, the program can be modified to suit your needs. Others may avoid telling the therapist important information because they are embarrassed by the content of their thoughts or the nature of their rituals. Keeping this information to yourself means that the treatment program will not be comprehensive and ensures that the outcome will not be as successful as it could have been. As mentioned at the start of this Manual, your therapist will have dealt with many Obsessive-compulsive disorder sufferers and no doubt will have heard of problems such as yours many times over. These types of thoughts and rituals are quite common among sufferers, even though they may seem bizarre or strange to you.

Another important issue ties in with motivation. By attending the clinic, you have decided that it is time to work on your Obsessive-compulsive disorder problems. That is exactly what you should focus on doing to the exclusion of all else except the essentials. Your progress will be impeded if you have to deal with other issues such as moving to another house, leaving your partner, starting a new job, and so forth. It is essential that you set aside the time to work on your problems without the distraction posed by these other issues. If distractions are pressing, deal with them before commencing treatment and allow some time for yourself to come to terms with the changes.

The final important issue is that of self-mastery.

As you progress through the program, you will gradually gain confidence in dealing with the Obsessive-compulsive disorder problems. In order to gain this sense of mastery over the problem, it is essential that you do not use anxiety-reducing drugs, illegal drugs, or alcohol while participating in the program, as use of such substances results in your attributing positive changes to the drugs rather than to yourself.

The treatment program

In previous sections an outline of the rationale and principles of treatment have been discussed. This section will review some of the important points and discuss the design of your treatment program. As mentioned above, treatment consists of repeatedly exposing the individual for prolonged periods (45 minutes to 2 hours) to circumstances that produce discomfort. In the initial sessions, such exposure will be under the supervision of your therapist, who will be with you throughout the task. Sessions may be conducted at the clinic, at your home, or in other settings where the rituals are a problem. The exposure is graded so that moderately disturbing situations are effectively dealt with before you proceed to more difficult ones. By breaking down the problems into steps and mastering each step before moving on to the next, you will find that what may seem like insurmountable problems become manageable. The sessions are held daily, with daily homework tasks being set during each session.

The importance of homework tasks cannot be overestimated, as it is with performance of these tasks that most of the treatment gains will occur. It is of little use to engage in the exposure and response prevention only while at the clinic. By completing your homework tasks faithfully, you are ensuring that what is being achieved at the clinic will transfer to the outside environment as well as reinforcing what has been learned during each session. Throughout the exposure, individuals are requested to refrain from ritualizing, regardless of the urges to do so. You should be prepared to experience some discomfort but you can rest assured that it will be considerably less than what you will anticipate. In fact, this is one of the major difficulties when describing this type of treatment to patients. Most sufferers fear that when exposed to a stimulus that evokes discomfort their anxiety will continue to rise for as long as they do not perform the ritual, until it eventually becomes unbearable. This is not the case. As described in previous sections, the discomfort will peak and then gradually decay, and each subsequent exposure will be less distressing and the decay will occur more rapidly.

Program design

The first step in designing your individual program is to conduct a thorough analysis of your difficulties by breaking down the problem into its various components.

Rituals are often triggered by thoughts, images, situations, events or feelings. In the sections below, you need to list your mental or behavioral rituals and the thoughts, situations or cues that trigger the urge to perform the ritual or lessen the anxiety. Some examples are listed to help you determine the triggers to the rituals and the rituals themselves. Your treating clinician will assist in your ratings of discomfort for each of the items. Subjective units of distress stands for subject units of discomfort

Avoidance

Individuals with Obsessive-compulsive disorder will often avoid situations that will provoke the thoughts or urge to ritualize. For example, someone with intrusive blasphemous thoughts may avoid church or anything of a religious nature. Someone with a fear of being contaminated may avoid hospitals, doctors’ surgeries, people who are ill, etc. In this section, please list all situations, objects, etc. that you avoid because they will cause you discomfort.

Exposure tasks

The next phase in developing your program is to determine the exposure tasks and timetable them according to your ratings of discomfort so that, to begin with, you will be exposed to the least anxiety-provoking situation. Once this is mastered, you will move on to the next more difficult item.

Before moving on to this next phase, it is important to establish some ground rules with your therapist. The purpose of these rules is to ensure that you gain maximum benefit from treatment.

First, there need to be some limits set on your ritualized behaviors. If you wash compulsively, then certain limits will be set as to when you can wash, for how long, how much soap can be used, and so forth. If you check compulsively, there will be limits put on what you can check, how often, and so forth. These limits are to be in force 24 hours per day. The reasons are really quite obvious. If you are exposed to a situation or object that causes you discomfort and then resist the urge to ritualize for the required period, there is little gained if you subsequently engage in rituals because you have come in contact with some other stimulus. These rules will be set each week in consultation with your therapist.

Second, there is to be no enlisting of family members to perform your rituals, e.g., having them wash clothes or floors, or check doors, the stove, and so forth. By getting family members to do such things for you, you are in fact feeding the problem rather than overcoming it. Members of the family can certainly be enlisted to help you with your exposure tasks and your response prevention, but they should not be used to maintain the problem.

In the following forms, you and your therapist can list the ground rules for the planned daily tasks and the homework assignments. There is also the opportunity for you to make note of any difficulties encountered during the program.

Towards the end of the program, a new phase called overlearning will be introduced. This phase is an important part of treatment during which the exposure tasks are designed to ensure the consolidation of what has been learned during treatment. Your therapist will discuss this process with you when the time arises.