The next step is to help you to feel more in control of your reactions. We will do this in several parts. First, there are many simple things you can do in your day-to-day life that will make you feel more in control and less distressed. There is nothing magical about these “Hints for coping” – most are simply common sense – but they can make a real difference. The second part involves more specific strategies that your therapist will teach you to control your anxiety and distress. Some of these are useful in lowering your overall level of tension and stress – the more relaxed you are in general, the better you will cope when the memories return or you are confronted with other unexpected difficulties. Everyone experiences increases in anxiety and distress at those times. If your overall level of stress is high, these escalations will take you up into the level of high anxiety and panic (the top graph in the figure above). If your overall level is lower, the shape will be the same – you will still react to negative events, but your anxiety and distress will not reach the same heights (the lower graph in the figure). We will call these “routine strategies”, since we want them to become part of your everyday routine. Examples would be regular exercise, rest, sensible diet, and relaxation. Other strategies are designed to help you to deal more specifically with difficult situations when you can feel your anxiety escalating and you are beginning to feel overwhelmed. These require a lot of practice, but are very useful to use when the feelings of distress and anxiety are particularly strong.
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.