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PosttraumaticStressDisorder

PatientTreatmentManual
This manual is both a guide to treatment and a workbook for persons who sufferfromPosttraumaticStressDisorder.Duringtreatment,itisaworkbook inwhichindividualscanrecordtheirownexperienceoftheirdisorder,together withtheadditionaladvicefortheirparticularcasegivenbytheirclinician.After treatment has concluded, this manual will serve as a selfhelp 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,staywell.
From:TheTreatmentofAnxietyDisorders. AndrewsG,CrinoR,HuntC,LampeL,PageA. NewYork:CambridgeUniversityPress(1994)

Purchasersofthebookmaywishtophotocopyportionsofthetextofthismanualforusewiththeirpatients. Thisisacceptabletothepublisher,who,nevertheless,disclaimsanyresponsibilityfortheconsequencesofany such use of this material in clinical practice. It is not necessary to write to Cambridge University Press for permissiontomakeindividualphotocopies.Thispermissiondoesnotextendtomakingmultiplecopiesforuse bythepurchaser,forusebyothers,orforresale.Individualsorclinicsrequiringmultiplecopiesmaypurchase themfromCambridgeUniversityPressusingtheorderformatthebackofthebook.


ClinicalResearchUnitforAnxietyDisorders St.VincentsHospitalSydney
2010

www.crufad.org

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Section1 Introduction Experienceofatraumaticeventcanshatteraperson'slife,leavingthemfeelingvulnerable andfrightened.Itisveryimportanttorememberthatrecoveryispossibleandthatyoucanleada normal,happylifeagain.Thisdoesnotmeanthatyouwillforgetwhathappenedtoyouorthatyou willneveragainbedistressedbymemoriesandremindersoftheevent.Acertainamountofdistress whenyouthinkaboutwhathappenedispartofbeinganormal,caringhumanbeingandwecertainly donotwantyoutohavenofeelings.However,thedistresswillbecomelessfrequentandmore manageableitwillnolongercontrolyourlifeasitmaydonow.Recoveryalsodoesnotmeanthat youwillbeexactlythesamepersonthatyouwerebeforethetrauma.Suchpowerfulexperiences maychangepeopleinmanyways,notallofthemnegative.Aspeoplerecoverfromtrauma,theymay findthemselvesstrongerthanbefore,perhapsmorecaringandwithamorebalancedandsensible viewaboutwhatisimportantintheirlives. Byseekingsomehelp,youhavetakenthefirststepstorecovery.Thepurposeofthismanual istohelpyouthroughthetreatmentprocessinastepbystepfashion.Thereisagreatdealof informationheretakeitslowlyandreadeachsectionasoftenasnecessaryuntilyouunderstandit beforemovingon.Youwillbeaskedtowritethingsdownfromtimetotime,sowesuggestthatyou findanexercisebooktouseforthosetasksthatyouwillkeepaddingtothroughoutyourrecovery. Trynottoworryifitallseemstoodifficultatthemomentrecoveryfromtraumaisoftenalong processandyouneedtotakethingsonedayatatime,recognisingsmallimprovementsasthey occur.Itcanbealongjourney,butitwillbeworthit.

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1.TheNatureofTraumaticStressandPTSD Atsomepointinourlives,nearlyallofuswillexperienceaveryfrighteningordistressing eventthatwillchallengeourviewoftheworldorourselves.Virtuallyeveryonedevelopssomekind psychologicalreactionfollowingsuchexperiencesthisispartofanormalhumanresponseto extremestress.Mostpeoplewillrecoverovertheweeksandmonthsfollowingtheincidentwiththe helpofcaringfamilymembersandfriends.Forsome,however,recoverydoesnotcomesoeasilyand moreseriousproblemsdevelop.Inthosecases,professionalhelpisoftenrequired. Someindividualswhoexperienceatraumaticeventwillgoontodevelopachroniccondition knownasPosttraumaticStressDisorder(PTSD).Theexactnumbersaredifficulttospecify,but anywherebetween5%and40%oftraumasurvivorsmaydevelopPTSD.Thequestionofwhysome peopleareaffectedmorethanothershasnosimpleanswermanyfactorsareinvolved.Itseemsto beacomplexmixofwhatthepersonwaslikebeforethetrauma,theirexperienceofother frighteningeventsinthepast,theseverityofthecurrenttrauma,andwhatelseishappeningintheir livesastheytrytorecover.Regardlessofthecauses,effectivetreatmentdoesagreatdealtoimprove thechancesofrecovery. 1.1WhatIsaTraumaticEvent? Traumaisaverypersonalthing.Whattraumatisesonepersoncanbeoflesssignificanceto others.Thisvariationinpeoples'reactionsoccursbecauseoftheirindividualpersonality,beliefs, personalvalues,andpreviousexperiences(especiallyofothertraumaticeventsintheirlife).Itoccurs alsobecauseeachperson'sexperienceoftheincidentisunique.However,inallcasestheindividual hasexperiencedathreateningeventthathascausedthemtorespondwithintensefear, helplessness,orhorror.Thethreatorinjurymaybetothemselvesortoothersclosetothem.Typical
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traumaticeventsmaybeofhumanorigin(suchaswarexperiences,physicalassault,sexualassault, accidents,andwitnessingthedeathorinjuryofothers)orofnaturalorigin(suchasbushfires, earthquakes,floods,andhurricanes).Overall,therearenohardandfastrulestodefinetrauma. 1.2WhatisPTSD? PTSDisapsychologicalresponsetotheexperienceofintensetraumaticevents,particularly thosethatthreatenlife.Itcanaffectpeopleofanyage,cultureorgender.Althoughwehavestarted tohearalotmoreaboutitinrecentyears,theconditionhasbeenknowntoexistatleastsincethe timesofancientGreece(morethan2000yearsago)andhasbeencalledbymanydifferentnames.In theAmericanCivilWaritwasreferredtoassoldiersheart,inWorldWarIitwascalledshell shock,whilebyWorldWarIIitwasknownaswarneurosis.Incivilianlife,termssuchas"shock neurosis","railwayspine",and"rapetraumasyndrome"wereusedinthepast. Traumaticstresscanbeseenaspartofanormalhumanresponsetointenseexperiences. Whilemostpeoplerecoveroverthefirstfewmonths,formanythesymptomsdonotseemtoresolve quicklyand,insomecases,maycontinuetocauseproblemsfortherestoftheperson'slife.Itisalso commonforsymptomstovaryinintensityovertime.Somepeoplegoforlongperiodswithoutany significantproblems,onlytorelapsewhentheyhavetodealwithothermajorlifestress.Inrarecases, thesymptomsmaynotappearformonths,orevenyears,afterthetrauma. 1.3CommonSymptomsofPTSD PTSDischaracterisedbythreemaingroupsofproblems.Theycanbeclassifiedunderthe headingsofintrusive,avoidantandarousalsymptoms: 1.3.1IntrusiveSymptoms Memories,images,smells,sounds,andfeelingsofthetraumaticeventcanintrudeintothe livesofindividualswithPTSD.Sufferersmayremainsocapturedbythememoryofpasthorrorthat
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theyhavedifficultypayingattentiontothepresent.PeoplewithPTSDreportfrequent,distressing memoriesoftheeventthattheywishtheydidnothave.Theymayhavenightmaresoftheeventor otherfrighteningthemes.Movement,excessivesweating,andsometimesevenactingoutthedream whilestillasleepmayaccompanythesenightmares.Theysometimesfeelasthoughtheeventswere happeningagain;thisisreferredtoasflashbacks,orrelivingtheevent.Theymaybecome distressed,orexperiencephysicalsignssuchassweating,heartracing,andmuscletension,when thingshappenwhichremindthemoftheincident.Overall,theseintrusivesymptomscauseintense distressandcanresultinotheremotionssuchasgrief,guilt,fearoranger. IntrusiveSymptomsofPTSD: Distressingmemoriesorimagesoftheincident Nightmaresoftheeventorotherfrighteningthemes Flashbacks(relivingtheevent) Becomingupsetwhenremindedoftheincident Physicalsymptoms,suchassweating,heartracing,ormuscletensionwhenremindedofthe event 1.3.2AvoidanceSymptoms Memoriesandremindersoftraumaticeventsareveryunpleasant,causingconsiderable distress.Therefore,peoplewithPTSDoftenavoidsituations,people,oreventsthatremindmaythem ofthetrauma.Theytrynottothinkabout,ortalkabout,whathappened,andattempttocut themselvesofffromthepainfulfeelingsassociatedwiththememories.Intheirattemptstodothis, theyoftenwithdrawfromfamily,friends,andsocietyingeneral.Theybegintodolessandless,no longertakingpartinactivitiestheyusedtoenjoy.Thismayhelpthemtoshutoutthepainful memories,butitcanalsoleadtofeelingsofisolationandofnotbelongingtotherestofsociety.In
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thiswaythepersoncanbecomenumbtotheirsurroundingsandnotexperiencenormaleveryday emotionssuchasloveandjoy,eventowardsthoseclosetothem.Suchreactionscanleadto depressionandproblemswithinthefamily.Theycanalsoleadtosevereproblemswithmotivation peoplewithPTSDoftenfindithardtomakedecisionsandtogetthemselvesgoing.Theymayhave difficultymakingtheefforttohelpthemselvesoreventodothingsthattheywouldpreviouslyhave foundenjoyableoreasy.Thiscanbeveryhardforfamilyandfriends,whooftenthinkthatthe suffererisjustbeinglazyordifficult. AvoidanceandNumbingSymptomsofPTSD: Tryingtoavoidanyremindersofthetrauma,suchasthoughts,feelings,conversations, activities,placesandpeople 1.3.3ArousalSymptoms Peoplewhohaveexperiencedatraumahavebeenconfrontedwiththeirownmortality.Their assumptionsandbeliefsthattheworldissafeandfair,thatotherpeoplearebasicallygood,andthat "itwon'thappentome",havebeenshatteredbytheexperience.Aftertheevent,theyseedanger everywhereandbecometunedintothreat.Asaconsequence,theymaybecomejumpy,onedge, andfeelconstantlyonguard.Thiscanleadtobeingoverlyalertorwatchfulandtohavingproblems concentrating(forexample,notabletoreadabookforlong,gettingonlyasmallamountofwork completedinafewhours,easilydistracted).Itiscommonforsleeptobeverydisturbeddifficulty
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Gapsinmemoryforgettingpartsoftheexperience Losinginterestinnormalactivities Feelingcutoffordetachedfromlovedones Feelingflatornumb Difficultyimaginingafuture

gettingoff,restlessnessthroughthenight,orwakingearly.Sometimespeoplefindthattheyare frightenedtogotosleepbecauseofthenightmaresorbecausetheyfeelunsafe. AngerisoftenacentralfeatureinPTSD,withsufferersfeelingirritableandpronetoangry outburstswiththemselves,othersaroundthem,andtheworldingeneral.Inpart,theangerisone wayofexpressingthefeelingsofbeingtenseandonedgethatareassociatedwithPTSDforsome peopleitiseasiertoacknowledgeangerthanfear.Inaddition,however,thisangerresultsfromthe feelingsofinjusticecausedbythetraumaareactiontothegrossunfairnessofitall.Angerand irritabilityfrequentlycausesmajorproblemsatwork,aswellaswithfamilyandfriends. ArousalSymptomsofPTSD: 1.4AssociatedProblems PTSDisnottheonlypsychologicalresponsetotrauma.Peoplemaydeveloparangeofother problemsthatcanaffecttheirqualityoflife,theirabilitytorelatetootherpeople,andtheircapacity forwork.Theseproblemsmayoccurontheirown,oraspartofthePTSD.Manyoftheseproblems arethoughttobetheresultofpeopletryingtocontroleitherthemselvesandtheirsymptoms(such asalcoholanddrugabuse)ortheirenvironment(suchasavoidancebehaviourandangryoutbursts). Also,manyofthesignsaredirectlyrelatedtostress(suchasskincomplaintsandgeneralachesand pains).Overall,themostcommonlyassociatedproblemsinPTSDarethoserelatingtoanxiety, depression,andalcoholordrugusewewilldiscusseachofthesebriefly.Theycanbeverydisabling
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Sleepdisturbance Angerandirritability Concentrationproblems Constantlyonthelookoutforsignsofdanger Jumpy,easilystartled

tothesufferer,andmayaffectfamilymembersandworkcolleagues.Manyofthefollowingproblems developovertimeasthepersonstrugglestocopewiththePTSD.Ifyouareintheearlystages followingatrauma,someofthefollowingmaynotapplytoyou. Anxiety:Anxietyisastateofapprehensionandworrythatsomethingunpleasantisaboutto happen.Itisoftenaccompaniedbyarangeofphysicalsymptoms(suchassweating,heartracing,and breathingdifficulties)whichare,inthemselves,veryfrightening.Sometimespeopleexperiencing thesesymptomsbelievethattheyaregoingtodiefromaheartattackorgocrazy.Anxietycanbe specifictocertainsituations(suchassocialevents,crowdedplaces,orpublictransport),oritcanbea generalstateofworryaboutmanythingsinourlives.Ifyouarehavingsignificantproblemsinthese areas,besuretotellyourtherapist.Treatment(asoutlinedinotherchaptersinthisbook)canbevery effective. Depression:Depressionisageneralstateoflowmoodandalossofinterestorpleasurein activitiesthatwereonceenjoyed.Lifebecomesflatandgrey,andnothingseemsfun,exciting,or enjoyableanymore.Thesedepressedstatescanbeveryintense,leadingtoatotalwithdrawalfrom othersandastateofnumbness,ortheycanbelowerinintensityjustfeeling"downinthedumps". Theymaylastforaslittleasafewhoursoraslongasmonthsorevenyears.Inmoreseverecases,the personmaybelievethatlifeisnolongerworthliving.ManypeoplewhosufferfromPTSDoveralong perioddevelopsignificantproblemswithdepression.Again,itisimportanttotellyourtherapistif theseproblemsapplytoyou.Itcanbetreatedeffectivelywithpsychologicaltreatmentsand/or prescriptiondrugs. Guilt:PeoplewithPTSDoftenreportstrongfeelingsofguilt,shame,andremorse.Thismaybe aboutthefactthattheysurvivedwhileothersdidnot;itmaybeaboutwhattheyhadtodoto survive;itmayberelatedtohowtheyhavecopedoractedsincethetrauma.Guiltisoftenthemost difficultthingtotalkabout,especiallyifyoufeelthatyoudidsomethingwrongoractedinabadway.
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However,itisveryimportantthatyouworkonthosefeelingsaspartofyourPTSDtreatmentsobe suretotellyourtherapistaboutthosefeelings. AlcoholandDrugs:Inanattempttocopewiththeunpleasantsymptoms,manypeopleturn toalcoholorotherdrugs.Althoughtheymayseemtohelpintheshortterm,theypreventtheperson fromrecoveringeffectivelyandleadtolongtermproblems.Drugandalcoholabuseimpairsthe person'sabilitytofunctioneffectivelyandtorelatetootherpeople.Itcancausegreatdifficultiesin areassuchasrelationships,work,finances,andviolentbehaviour. ImpactonRelationshipsandWork:Traumatisedpeoplecanbecome"consumed"bytheir feelings,whichmayleadotherstobelievethattheyareselfish,thinkingonlyofthemselves.Difficulty feelingandexpressingemotions(forexample,loveandenthusiasm),lossofinterestinsex,and reducedparticipationinactivitiesandhobbiesthattheyusedtoenjoybeforethetraumaare common.Traumatisedpeopleareoftentiredandcanbecomecrankyandirritable.Theymaysay hurtfulthingswithoutreallyconsideringtheimplicationsofwhattheyaresaying.Allofthese symptomsmaycausepartnerstofeelrejectedandunloved,andtheabsenceofsharedenjoyable activitiesmakesitdifficulttohaveanormalfamilylife.Itisveryimportanttokeepcommunicating aboutwhatishappeningtrytobereasonablyhonestwitheachotherabouthowyouarefeeling. PeoplewithPTSDmayhavedifficultycopingwithpressureatwork.Irritability,jumpiness, moodswings,poorconcentration,andmemoryproblemsmayleadtodisputesintheworkplaceand frequentjobchanges.SomepeoplewithPTSDadoptaworkaholicpattern,shuttingthemselvesaway intheirworkandputtinginverylonghours.Thisseemstobepartoftheavoidancecomponentof PTSDkeepingverybusyhelpstopreventthememoriesandunpleasantthoughtscomingbackbut itdoesnothelpinthelongterm.Othersfindthattheirproblemsprohibitthemfromworking effectivelyatall.

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1.5WhyDoTraumaticStressReactionsDevelop? ItisimportanttounderstandwherethesignsandsymptomsofPTSDcomefrom.Oneofthe leadingcliniciansinthearea,MardiHorowitz,describedtraumaasanexperiencethatis,byitsvery nature,overwhelming.Itcontainslotsofnewinformationthatishardtoacceptorunderstand.It doesnotfitwithourviewoftheworldorourselvesthewaywethinkthingsareorshouldbe. Humanbeingshaveanaturaltendencytotryandmakesenseofthingsthathappenaroundthem. Whenpeopleexperienceatrauma,theeventkeepscomingbackintotheirmindinanattemptto makesenseofwhathappened.Thisisthebody'snaturalwayoftryingtodealwith,orcometoterms with,difficultexperiencesandseemstoworkwellformanystressfullifeevents.However,duetothe highlevelofdistressassociatedwithmemoriesofmoreseveretrauma,thethoughtsandfeelings tendtobepushedawaytoprotectthepersonfromthisdistress.Theresultisthat,whilstthememory maygoawayforawhile,theneedforittobedealtwithhasnotbeenaddressedanditkeepscoming back.Themovementbackwardandforwardfromintrusivethoughtsandfeelingsaboutthetrauma toavoidanceandnumbingcanthencontinuealmostindefinitelyunlessthecycleisaddressedin someway. Throughoutthisalternatingbetweenshortburstsofpainfulmemoriesandperiodsof avoidanceandnumbing,thesenseoffeelingkeyeduppersists.Thetraumatisedpersonhasbeen throughaneventthatthreatenedtheirlife,orthelifeofsomeoneelse,sothemindandbodystayon alerttomakesurethatnofuturepotentialdangerswillbemissed.Itissafertogetitwrongby overestimatingpotentialthreatthantoriskthepossibilityofmissinganyfuturethreat.Thepersistent activationofthisthreatdetectionsystem,however,leavesthetraumatisedpersonfeelingkeyedup oronedgemuchofthetime.Inaddition,thethreatdetectionsystemissosensitivethatitis constantlygoingoffwhenthereisnodangerinsuchawaythatinterfereswiththepersonscapacity toliveanormalandhappylife.
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Traumaticstressreactions,therefore,aresensibleandadaptivebothaspartofsurvivalduring thetraumaandinattemptstocometotermswiththetraumaafterward.Oncewerecognisewhere thesesymptomscomefrom,itiseasiertounderstandthetypicaltraumaticstressreactions.The difficultpartislettinggoofthesereactionsnowthattheyhaveceasedtoprovidebenefitandare interferingwiththetraumatisedpersonsqualityoflife. 1.6TheProcessofTreatmentAndRecovery Youhavealreadystartedthefirststageofrecoverybyacknowledgingyourreactionstothe traumaticevent.Presumably,youhavealsotakenthenextstepofseekingappropriatetreatment fromamentalhealthprofessional.Gettinghelpisoftenfrighteningformany,itisaleapintothe unknownbuttryingtorecoverfromPTSDonyourownismuchmoredifficult.Treatmentusually involvesseveralstages;wewillgothrougheachoftheseinturn. PTSD:Stagesoftreatment: 1. Crisisstablisationandengagement 2. EducationaboutPTSDandrelatedconditions 3. Strategiestomanagethesymptoms 4. Traumafocussedtherapy(confrontingthepainful memoriesandfearedsituations) 5. Cognitiverestructuring(learningtothinkmore realisticallyaboutwhathappened) 6. Relapsepreventionandongoingsupport Itisimportanttorememberthattreatmentcanbepainfulandhardwork.Unfortunately, thereisnoeasywaytogetridofthememoriesormakethemlessdistressing.Thereisnomagic
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wandthatyourtherapistcanwaveortabletthatyoucantaketomakeitallgoaway.Butthelong termgainscanbeenormous:effectivetreatmentcandramaticallyassistyourrecovery,helpingyou toliveanormallifeonceagain.

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Section2 2.StabilisationofaCrisisandEngagementinTreatment Peoplewhohavebeenthroughatraumaoftenhaveotherdifficultsituationstodealwithin theaftermath.Thesemaybelegalissues,familydisruptions,financialproblems,oramultitudeof othercrises.Itisimportantthatanycurrentlifecrisesareresolved,oratleastput"onhold",before therealtreatmentofPTSDcanbegin.Itisnotpossibletodevotethenecessaryconcentration,time, andenergytoyourrecoveryifyouareconstantlyworriedaboutyourjob,yourrelationship,your children,orotherimportantlifeareas.Thatisnottosaythatyouhavetobeabletosolveallthose problemsbeforeyoucanworkonyourPTSD,butyouwillneedtobeabletoputthemtoonesidefor awhiletoconcentrateonyourtreatment.Therapyishardworkthereisnoeasywaytodoitand youwillneedtodevoteallyourpersonalresourcestothetask.Ifotherlifeissuesareworryingyou,it isimportantthatyoudiscussthesewithyourtherapistastheyarisesothattheydonotinterferetoo muchwithyourtreatment. Thefirstpartoftreatmentwilloftenbedevotedtodevelopingarelationshipwiththe therapist(orthetreatmentteamifyouaretakingpartinagroupprogram).Youwillneedtospend sometimegettingtoknoweachother,andbuildingtrust,ifyouaretoworkonthedifficultissues. Wecallthisprocess"engagement".FormanypeoplewithPTSD,thisisaverydifficultprocess experienceofatraumaticeventoftenmakesitveryhardtotrustanotherperson,particularly someonewhoyouhavenevermetbefore.Inmanycases,youwillneedtotellyourtherapistabout experiencesandfeelingsthatyouhaveneverdiscussedwithanyone.Weneedtorecognisethatthis isadifficultprocessthatwilltakealotofcourage,butitwillbeworthitanditistheonlywayto recovery.
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Section3 3.EducationandInformation PTSDcansometimesfeellikeanincomprehensiblecloudthathangsoverallareasofthe person'slife.Thefirststepintreatmentistounderstandexactlywhattraumais,whywehavethe symptomswedoand,therefore,whyitistreatedthewayitis.Inthisregard,youhavecomealong wayalreadybyreadingthesectionsabove.Youneedtoknowwhatthecommonsignsandsymptoms are,andyouneedtorecognisethatyouarenotalonemanypeoplewhohaveexperienced traumaticeventshaverespondedinexactlythesamewayasyouhave.Youneedtounderstandwhy thesymptomshaveappearedthefactthattheywereveryusefulforsurvivalwhilethetraumatic eventswerehappeningbutthattheyarenolongeruseful.Theyhavebecome"maladaptive"andnow onlyservetocreateproblemsanddistressforyou.Youneedtounderstandwhattreatmentwill involveandhowitmayaffectyou.Itisveryimportantthatyoufeelabletoaskyourtherapist questionsaboutthenatureofyourproblemsandtheprocessoftreatment.Heorshewillnothaveall theanswers,buttogetheryouwillreachabetterunderstandingofwhathashappenedandhowyou willrecover. Sometimes,peoplewhohavebeenthroughatraumaticeventhavetroubleunderstanding whathappenedandwhyithappened.Youmayfindyourselfconstantlyaskingquestionssuchas "howdidthishappen"or"whyme?"Thisispartlybecause,whenweareunderthreat,ourattention isveryfocussedonthesourceofthedangerandwedonottakeinalltheotherthingsthatare happeningaroundus.Wemayendupwithadistortedandconfusedmemoryoftheexperience,so thatitbecomesdifficulttounderstandandmakesenseoftheevent.Thisconfusionoftenstopsus frombeingabletoputtheexperiencebehindus.Forthisreason,yourtherapistmayhelpyoutofind outmoreaboutwhathappenedduringtheevent.Thisprocessisimportantinbeingableto"putthe piecesofthejigsawpuzzletogether"andmakesenseofyourexperience.Agoodunderstandingof
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exactlywhathappened,andwhyithappened,oftenfacilitatesrecovery. Althoughwehaveputthisundertheheadingof"EducationandInformation",itisactually somethingthatmayhappenatseveralstagesthroughouttreatmentandyouneedtomakesurethat youarereadybeforeyoupursuetheseoptions.Whenyouarefeelingreasonablyconfident,however, askyourselfwhatotherinformationyouneedtohelpyouunderstandwhathappenedandwhyit happened: Isthereanyoneelseyoucantalktowhomaybeabletoclarifythingsforyouandhelpyou reachabetterunderstandingofyourexperience(suchasotherswhowerethere,police officers,orambulanceofficers)? Isthereanythingyoucanreadthatwillhelptofillinthemissingpieces(suchasmedia reports,policestatements,orreportsfromatrialorCoroner'sInquest)?Sometimes, readingaccountswrittenbyothersurvivorsoftraumacanbeusefulinunderstandingyour reactions. Occasionallytheremayevenbevideofootageavailablefromnewsreportsorother sources:Isthereanythingyoucanwatchthatwillhelpyoufillinthegaps? Unfortunately,ofcourse,itisnotalwayspossibletofillinallthegapsinyourunderstandingof theevent.Sometimeswemayneverfindoutexactlywhathappened(or,morecommonly,whyit happened)andtreatmentneedstofocusonhelpinguslearntolivewiththatuncertainty.

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Section4 4.ManagingAnxietyandDistress Thenextstepistohelpyoufeelmoreincontrolofyourreactions.Wewilldothisinseveral parts.First,therearemanysimplethingsyoucandoinyourdaytodaylifethatwillmakeyoufeel moreincontrolandlessdistressed.Thereisnothingmagicalaboutthese"HintsForCoping"most aresimplycommonsensebuttheycanmakearealdifference.Thesecondpartinvolvesmore specificstrategiesthatyourtherapistwillteachyoutocontrolyouranxietyanddistress.Someof theseareusefulinloweringyouroverallleveloftensionandstressthemorerelaxedyouarein general,thebetteryouwillcopewhenthememoriesreturnoryouareconfrontedwithother unexpecteddifficulties.Everyoneexperiencesincreasesinanxietyanddistressatthosetimes.Ifyour overalllevelofstressishigh,theseescalationswilltakeyouupintothelevelofhighanxietyandpanic (thetoplineinFigure1).Ifyouroveralllevelislower,theshapewillbethesameyouwillstillreact tonegativeeventsbutyouranxietyanddistresswillnotreachthesameheights(thelowerlinein Figure1).Wewillcallthese"routinestrategies"sincewewantthemtobecomepartofyoureveryday routine.Exampleswouldberegularexercise,rest,sensiblediet,andrelaxation(seebelow).Other strategiesaredesignedtohelpyoudealmorespecificallywithdifficultsituationswhenyoucanfeel youranxietyescalatingandyouarebeginningtofeeloverwhelmed.Theserequirealotofpractice, butareveryusefultousewhenthefeelingsofdistressandanxietyareparticularlystrong.

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Quickstrategiesto manageescalations Anxiety Highanxiety &panic Routinestrategiesto loweroveralllevels Time Figure1:Reducingyourgeneralleveloftensionandmanagingescalationsinanxiety 4.1HintsForCoping Thefollowingisalistoftipsthatmanypeoplefinduseful.Donottrytodoeverythingatonce. Whenyouhavereadthefollowingsections,youmaywishtostopforawhileandworkouta"planof action".Whichstrategiessoundparticularlyusefulforyou?Whichonesareyoupreparedtotry?We suggestthatyouselectonlyoneortwotobeginwith.Workoutaplantoachievethem,oneata time,andsetyourselfsomerealisticgoalsforthenextweek.Attheendoftheweek,reviewyour progress:modifyyourgoalsifnecessaryand/ortrysomeadditionalstrategiesforthefollowingweek. Overtime,youwillgraduallydeveloparangeofcopingstrategiesandchangestoyourlifestylethat
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willhelpyoutofeelmoreincontrolofyoursymptomsandgetmoreoutoflife. Eathealthymeals.Thissoundssosimple,buthowmanyofusactuallydoit?Apoordiet (especiallyjunkfoodwithlotsofsugar)willincreaseyourstresslevelsifindoubt,talkto yourgeneralpractitioneroradietician. Getregularaerobicexerciselikewalking,jogging,swimming,orcycling.Exerciseisvery effectiveinmanagingstress.IfyouhavePTSD,yourbodyisconstantlygearedupfor"fight orflight".Exercisehelpstoburnupthosechemicals(likeadrenalin)thatarehypingyouup anditwillhelpyoutobecomemorerelaxed. Getenoughrest,evenifyoucan'tsleep.Restwillhelptoincreaseyourreservesof strengthandenergy.(Seealsothesectionbelowon"SleepingBetter"). Establish,andtrytostickto,dailyroutines(e.g.,gotobedandgetupatasettime,plan youractivitiesfortheday).Routineisveryimportantinhelpingustofeelincontrolandto functioneffectively.Ifyoufeelable,returntowork,study,orotherroutinesassoonas possiblebuttakeiteasydon'texpecttoomuchofyourselfanddon'tuseworkasaway ofavoidingpainfulfeelings. Askforsupportandhelpfromyourfamily,friends,church,orothercommunityresources whenyouneedit.Thisisnotasignofweakness.Ingeneral,otherpeopleareverykeento helpaslongasyouletthemknowwhatyouwant.Iftheydonotoffer,itmaysimplybe becausetheyareunsureofwhattodo. Spendtimewithotherpeople,butdon'tfeelthatyouhavetotalkaboutthetrauma.Talk aboutfootball,books,ortheweather;gotoamovieoraconcert;trytodosome enjoyablethingswithothers.Thisispartofresuminganormallife. Focusonyourstrengthsandcopingskills.Itmaynotfeellikeitattimes,butyouhave manystrengthsandstrategiestodealwithdifficulttimes.Rememberthatyouarenot
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alone.Lotsofothersurvivorsoverthecenturieshaveexperiencedthesekindsof problemsandthevastmajorityhaverecoveredwell. HintsForFamilyAndFriends PartnersandclosefriendsareoftenatalossastohowtohelpsomeonewithPTSD.Thereare severalthingsthatlovedonescandotohelpthetraumatisedperson.Youmayfindthefollowing suggestionsuseful. Ifpossible,listenandempathisewhenthetraumatisedpersonwantstotalk.Remember thatitmaybeveryhardforthemtoexpresswhattheyaregoingthrough.Asympathetic listenerisimportantinminimisingthetendencyofpeoplewithPTSDtowithdrawand "shutdown". Itisbestnottosay"Iunderstandwhatyou'refeeling"(youprobablydon't,sinceyou haven'tbeenthroughthesameexperiences).Instead,showyourempathybycomments suchas"itmustbereallydifficultforyou;Icanseethatitupsetsyou;isthereanythingI candotohelp?" Spendtimewiththetraumatisedperson.Thereisnosubstituteforpersonalpresence. Justkeepdoingtheusualthingsthatpeopledotogether.Donotfeelthatyouhavetotalk aboutthetraumaorbetheircounsellor.Justbeingwithpeoplewhocareaboutthemis veryimportantfortraumatisedindividuals.Equally,trytorespecttheperson'sneedfor privacyandprivategriefattimes. Don'ttellsurvivorsthattheyareluckyitwasn'tworseortopullthemselvestogether andgetoverit.Theyarenotconsoledbysuchstatements.Tellthem,instead,thatyou're sorrytheywereinvolvedinsuchanevent,andthatyouwanttounderstandandassist them. Reassurethemthattheyarenowsafe.
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Careabouteachother.Givehugs.Telleachotherhowmuchtheyareappreciated.Offer praise.Makeapointofsayingsomethingnicetoeachothereveryday.Goodrelationships arecharacterisedbylotsofpositiveinteractions,buttheyrequirehardwork.

HintsForSleepingBetter SleepdisturbanceisverycommoninbothPTSDanddepression.Medicationsometimeshelps, butitshouldbeusedwithcautionandonlyasdirectedbyyourmedicalpractitioner.Thereare severalsimple"nondrug"strategiesyoucantrythatcanbeveryhelpfulinimprovingsleep: Getintoaregularroutine.Inparticular,getupatthesametimeeachmorningevenifyou haven'tsleptwell. Ifyouarenotasleepwithin30minutes,getupforawhilebeforereturningtobed.Ifyou don'tdropoffwithin30minutes,getupagainandsoon. Trytoavoidcaffeine(coffee,tea,cola,chocolate)from6pmonwards.Avoidalcoholand, ifpossible,cigarettesfromdinnertimeonwards.Trynottoeatamealwithinacoupleof hoursofgoingtobed. Startingagentleexerciseroutineandlosingsomeweightoftenhelpswithsleep. Don'tdoanythinginbedexceptsleep(and,perhaps,sex):don'twatchTV,read,do crosswords,orthinkaboutworryingthings.Reservebedforsleeping. Getintothehabitofdoingsomethingrelaxingbeforebed:listentoarelaxationtapeor somerelaxingmusic,haveawarmbath,slowdown! Trynottoworryaboutnotsleeping:themoreyouworryaboutit,thelesslikelyyouareto dropofftosleep.Youcansurvivewithoutmuchsleep,eventhoughyouwillbetired. Sleep,likeanyhabit,takesawhiletochange.Trytosticktotheaboveguidelinesforat leasttwoweeksbeforedecidingwhetherornottheyhelp

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4.2OverviewOfAnxietyManagement Whenweexperienceaveryfrighteningorunpleasantevent,ourbodygearsitselfuptofight thethreatortorunaway(the"fightflight"response).Ifthethreatissmallandpasses,ourbody quicklyreturnstonormal.Ifthethreathasbeenmajor,however,orifthereisongoingdanger(or stress),ourbodyremainsinastateofalertnessreadytoreactimmediatelyifthethreatreappears. Thischronicstateofalertnessaffectsusinmanyways.First,wetendtostayphysicallyhypedupand arousedallthetime.Ourheartrateandbreathingareincreased,andourmusclesremaintensedup, leadingtoallsortsofunpleasantphysicalsensations,aches,andpains.Second,ourthinkingis affected.Wemayfindithardtoconcentrate,rememberthings,andmakedecisions.Memoriesofthe trauma,orthoughtsoffuturedanger,seemtoconstantlycometomindevenwhenwedonotwant themto.Third,ourbehaviourisaffected.Experienceofthetrauma,aswellastheunpleasantsigns andsymptomsthatmayfollow,causespeopletofeelscaredandvulnerable.Inanattempttocope, theymaytrytowithdrawfromotherpeopleandtheoutsideworld,shuttingdownasameansofself protection.Ifwearetoeffectivelymanagetheanxietyanddistressthatfollowsatraumatic experience,wewillneedtoaddressallthreeaspects:thephysicalcomponents,thethoughts,andthe behaviour. Itisimportanttorememberthatthegoalisnottomaketheunpleasantfeelingsgoaway altogetherthatisneitherpossiblenordesirable.Rather,thegoalistokeepthemmanageableto keepthemundercontrolandtostopthemescalatingintoextremeanxietyandpanic.Practiceis essentialtomastermostofthefollowingtechniques.Trytosetasidesometimeeachday(preferably twiceaday)topractice.Ifyouwaituntilyouaretenseandfrightenedbeforeyoutrythetechnique,it willnotwork.Onceyouhavepracticedthemregularly,however,theywillbecomemoreautomatic andeffective.Theywillbecomeimportanttoolsinhelpingyoutomanageanxietyanddistress.Keep adiaryofyourpracticesessions,notingdowntheSUDSlevel(seebelow)beforeandafter.Thiswill
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givebothyouandyourtherapistagoodideaofhowyouareprogressing. Thefollowingsectionsdiscussstrategiesineachofthethreedomains.Otherchaptersinthis bookcontainverygooddescriptionsofseveralanxietymanagementstrategies.Youmaywishtotalk toyourtherapistaboutgettingcopiesofsomeoftherelevantsections. 4.3SubjectiveUnitsofDistress(SUDS) Asyoustarttoconqueryourfears,itbecomesveryimportanttohaveameansofmeasuring yourlevelofanxietyanddistress.WesuggestthatyouuseaSUDSscalerangingfrom0to100akind offearthermometerwhere0isfeelingperfectlyrelaxedand100istheworstanxietyanddistress youcanimagine.Itisusefultogetintothehabitofratingyouranxiety.Thatway,youbecomemore intouchwithyourfeelingsandhaveabetterchanceofcontrollingthem.Withoutsomekindof measure,peopletendtothinkinblackandwhitetermseitheryouareanxiousorrelaxedwhen,in reality,therearemanyshadesofgrey.UsingtheSUDSscalewillhelpyoutokeepyourdistresslevel inperspective;forexample,youmaybefeelinganxious,butit'sonly40youcanhandlethat.Inthe exercisesthatfollow,trytorateyourdistress(usingtheSUDSscale)beforeyoutrytheanxiety managementstrategyandagainafterwards.Hopefully,itwillhavecomedown(ifonlyalittle).

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SUDS:TheFearThermometer

Totallyrelaxed

10

Alertandawake,concentratingwell

20

Tinyamountoftension/anxiety

30

Mildanxiety,nointerferenceonperformance

40

50

Moderatedistress:feelsuncomfortable butcancontinuetoperform

60

70

Quiteunpleasant,interferingwithperformance

80

Veryuncomfortable,cannotconcentratewell wanttoescapethesituation

90

Extremelyuncomfortable,havetoleave

100

Highestanxiety/distressthatyouhaveeverfelt

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4.4ManagingThePhysicalSymptoms Severalstrategieswillassistinmanagingtheunpleasantphysicalsymptomsassociatedwith traumaticstressandPTSD.Someofthesehavebeendiscussedaboveundertheheadingof"HintsFor Coping".Ifyoucangetsomeregulargentleexercise,eatproperly,getenoughrest,andtrytocut downonstimulants(suchascoffee,tea,cola,chocolate,andcigarettes),youwillgoalongway towardsreducingthechronicarousalthatispartofPTSD.Inthissection,wewilllookattwospecific strategiestoreducearousal.Thefirstisasimplebreathingcontrolstrategydesignedtoreduceyour rateanddepthofbreathingandhelpyoutofeelmorerelaxedandincontrol. Oftenwhenpeoplearefrightenedorupset,theystarttobreathefaster.Anincreasein breathingispartofthe"fightflight"responseweneedmoreoxygenifwearetofightorrunaway. However,breathingtoodeeplyandtoofastwhenwearenotusingupalotofenergytendstomake usmoreanxiousandoftencausesunpleasantphysicalsymptomssuchasdizziness,tightnessinthe chest,andafeelingofbeingshortofbreath.Whenweareupset,wemaybetoldtotakeafewdeep breaths.Thisisnotquiteright,however.Whenwearefeelinganxiousorfrightened,wedontneed totakeadeepbreath;weneedtotakeanormalbreathinandexhaleslowly.Breathingoutis associatedwithrelaxation,notbreathingin.Whileconcentratingonalong,slowexhalation,itisa goodideatosayawordlikerelaxor"calm"toyourself.Anywordthatisassociatedwithfeeling peacefulandateasewilldofine.Trytodragoutthewordtomatchthelong,slowexhalation,asin reeelaaaxorcaaaaalm. Thenextthingtorememberistoslowyourbreathingdown.Rememberthattakingintoo muchaircausesanincreaseinanxietyandunpleasantphysicalsymptoms.So,whatweneedtodois toslowourbreathingdownandtakeinlessair.Wedothisbytakingsmallerbreathsandbypausing betweenbreathstospacethemout.Itisalsoimportanttotryandbreatheinthroughyournose,not throughyourmouth.Whenyouhavetakenanormalbreathinthroughyournose,holdyourbreath
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foracountoffourbeforeexhalingslowly. Now,tryputtingitalltogether: Practicethistypeofbreathingatleasttwiceaday.Thatway,whenyoubecomefrightenedor anxious,youwillbereadytousethetechniquetohelpyoucalmdown. Thesecondphysicalinterventionwewilldiscussisrelaxationtraining,orprogressivemuscle relaxation(PMR).Thebreathingcontroldescribedabove,onceyouhavemasteredit,isanexcellent strategyfordealingwithrapidincreasesinanxietythatmayoccurwhenyouexperiencememoriesof thetraumaorfindyourselfinafrighteningsituation.PMRisdesignedtodealwiththemore pervasive,chronictensionandstressassociatedwithPTSD.Ifyoucanloweryourgenerallevelof arousalor"uptightness",youwillbemuchlesslikelytooverreactinresponsetominorperceived threats.Thisisjustlikeacoiledspringthemorewoundupitis,themorelikelyitistoexplodeunder pressure.Theworldwillseemlikeasaferplace. PMRisusuallydonebylisteningtoatape,whichwilltakeyouthroughaseriesofexercisesin whichyouwillbeaskedtotenseupandrelaxvariousmusclegroups.Bygraduallyworkingthrough yourwholebody,fromheadtotoe,youwillachieveastateofphysicalrelaxationthat,withpractice, youwillbeabletomaintainthroughmuchoftheday.Yourtherapistwillmakeatapeforyoutouse athome.Alternatively,manylibrariesorcommunityhealthcentreswillbeabletoprovideonefor you.Excellentdescriptionsofrelaxationtrainingappearinothertreatmentmanualscontainedinthis
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Takeinanormalbreaththroughyournosewithyourmouthclosed Pausebrieflywhileyoucounttofour Exhaleveryslowly(mouthopenorclosed,whicheverfeelsmostcomfortable) Saycalmorrelaxtoyourselfasyouexhale Repeatthewholesequence610times

bookandwillnotberepeatedhere.Ifyoudecidetotrythisapproach(andwestronglyrecommend thatyoudo),askyourtherapisttocopyoneoftherelevantsectionsforyou.Makingrelaxationa regularpartofyourdailyroutinewillgoalongwaytohelpyouinmanagingthephysicalsymptomsof PTSD. 4.5ManagingProblemsWithThoughts PeoplewithPTSDareoftentroubledwithmemoriesorotherunwantedthoughtsaboutthe trauma.Itisimportantthatyoudonottrytogetridofthesethoughtsandmemoriescompletely thinkingaboutwhathappenedisanimportantpartofcomingtotermswithitandputtingitbehind you.Equally,itisnothelpfultobethinkingaboutitallthetimethatsimplycausesunnecessary distressandpreventsyoufromgettingonwithyourlife.So,itisagoodideatolearnafewstrategies tocontroltheseunwantedthoughtssothatyoucanlimitthemtotimesthatdonotinterferetoo muchwithotheractivities. 4.5.1Distraction Onesimplewaythat,withpractice,canbeveryeffective,isdistraction.Anobviousexample wouldbegettingonwithanactivitythatisabsorbing(andhopefullyenjoyable)tooccupyyourmind. Canyouthinkofsomethingthatyoucoulddotodistractyourself?Passiveactivities(likereadingor watchingtelevision)donotusuallywork,asyourconcentrationmaynotbegoodenough.Rather,you willneedtodosomethingmoreactivethatinvolvesbothphysicalandmentalaspects.Games,crafts, andothercreativeactivitiesareoftengood. Itisalsogoodtopracticeapurelymentaldistractiontechniquethatyoucanuseanywhere, anytime.Therearemanythingsthatyoucouldtryandthefollowinglistprovidessomeexamples. Theyareparticularlygoodbecausenooneelsecanseeyoudoingthem.Donottrytodothemall pickoneortwothatfeelasthoughtheymayworkforyouandpracticeregularly.Evenwithpractice,
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youmustexpectthethoughtstointrudeagainfromtimetotime.That'sOKjustgobacktothe distractingthoughtsasoftenasnecessary. Strategiesformentaldistraction: Count&Relax:Breathenormally,likeyoumightwhenyou'rejustabouttodropofftosleep.As youbreathein,counttoyourself.Asyoubreatheout,say"relax"toyourself.Thatis,whenyou breathein,think"one";asyoubreatheout,think"relax";asyoubreathein,think"two",as youbreatheout,think"relax";asyoubreathein,think"three",andsoonfortenslowbreaths severaltimesaday.Don'tworryifotherthoughtsintrude,justgobacktothecountandrelax. Focusonasmallarea(e.g.,asquaremetreonthewallopposite),oronanobject,anddescribe itinminutedetaileveryline,shadow,andshape. Focusonyoursurroundingswithallsenses:describeindetailtoyourselfwhatyoucansee aroundyou,whatyoucanhear,whatyoucansmell,whatyoucanfeel(sensoryperceptionsof touch,notemotionsoranxietysymptoms).Trytodescribe5thingsyoucansee,5youcan hear,5youcanfeel,andsoon.Thisisparticularlygoodasitkeepsyouintouchwithreality "hereandnow". Mentalexercises:forexample,countingbackwardstoyourselffrom100in7'sornamingan animalbeginningwitheachletterofthealphabet Describetoyourselfingreatdetailahappyexperiencefromthepast(e.g.,aholiday,afamily occasion,afavouritewalk).Trytogothrougheveryaspectfromstarttofinish. Describeindetailaplace(perhapsfromyourpast)whereyoufeelsafe,secure,relaxed,and happy.Whereisit,whatdoesitlooklikeandsmelllike,whoistherewithyou,whattimeof dayisit,howdoesitfeel,andsoon.

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4.5.2ThoughtStopping Anotherstrategytodealwithunwantedthoughtsandmemoriesisknownas"thought stopping".Thisisasimpletechnique,butsurprisinglyeffectiveifyouaretroubledbyconstant thoughtsor"ruminations"aboutthetraumaifyoufindyourselfthinkingaboutwhathappened(or mighthavehappened)overandoveragain.(Note:Itshouldnotbeusedforthebriefandveryvivid memoriesthatjumpintoyourmindforshorterperiodsoftime).Ifyouwishtotrythoughtstopping, practiceitseveraltimesinthefollowingmanner.Placeanelasticbandroundyourwrist.Now, deliberatelybringtheunwantedthoughtsintoyourmindandletthemrunforaminuteorso.Then shouttheword"STOP"loudly(it'sbesttopracticethisoneonyourown!)andsnaptherubberband againstyourwrist.Thiswillinterruptyourtrainofthought.Repeatthisprocessoverandoveragain, graduallysayingSTOPmoreandmorequietlyuntileventually(afteradozenorsotimes)youare whisperingitandthensayingitjusttoyourselfinyourhead.Keepsnappingthebandeachtime.If youpracticethatwholeprocessacoupleoftimesadayforseveraldays,youwillgainmuchmore controloveryourthoughts.Youwillbeabletostopthethoughtswhenyouareinpublicwithout sayinganythingoutloud(althoughyoumaywishtokeeptherubberbandthereforawhileasa reminder). 4.5.3SelfStatements Onefinalareawewouldliketodiscussundertheheadingofmanagingthoughtproblemsis thatof"selfstatements".Atpresent,itislikelythatmanyofyourthoughtsarenegative:worrying aboutthesafetyofyourselforothers,concernedthatyouwillneverrecover,andsoon.These negativethoughtsfeedintoyouranxietyanddistress,makingitmuchworse.Wewilladdressthis issueagainlater.Forthetimebeing,wearegoingtosuggestthatyousimplyworkoutsomesimple thingsthatyoucansaytoyourselftohelpyoucalmdownandrelaxwhenyouareinadifficult
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situationorwhenyouarefeelingoverwhelmedbypainfulmemories.Afamouspsychologist,Donald Meichenbaum,hassuggestedthatweshouldbreakupeacheventintoseveralstages.First,whatcan wesaytoourselveswhenwearepreparingforsomethingdifficult?Thishelpsyoutoreevaluatethe actualprobabilityofthefearednegativeeventhappeningfollowingtrauma,mostpeople overestimatethelikelihoodofdanger.Second,whatcanwesayasweapproachandenterthe difficultsituation?Thiswillhelptoreducethedesiretoavoidandrunaway(whichwillonlymakeit moredifficultnexttime).Thethirdstageisdealingwiththefeelingsofanxietyanddistressasthey arise(topreventthemfrombecomingoverwhelming),andthefinalstageiswhenlookingbackonthe episode.Severalexampleofthingsyoucouldtrysayingtoyourselfareprovidedbelow. Examplesofselfstatementsforcopingwithstress: 1. 2. 3. Preparingforastressor: WhatisitIhavetodo? Whatisthereallikelihoodofanythingbadhappening? Don'tfocusonhowbadIfeel;thinkaboutwhatIcandoaboutit. Ihavethesupportofpeoplewhoareexperiencedindealingwiththeseproblems. Ihavealreadycomealongwaytowardsrecovery;Icangotherestoftheway. ConfrontingandHandlingaStressor: Onestepatatime;Icanhandlethis. Don'tthinkaboutbeingafraidoranxious,thinkaboutwhatIamdoing. ThefeelingsI'mhavingareasignalformetousemycopingexercises. There'snoneedtodoubtmyself.IhavetheskillsIneedtogetthrough. Focusontheplan.Relax...breatheasily,I'mreadytogo. CopingwithFeelingsofBeingOverwhelmed: Takeagentlebreathandexhaleslowly.
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4.

Focusonwhatishappeningnow,notwhatmighthappen;whatisitIhavetodo? Iexpectmyfeartorise,butIcankeepitmanageable. Thiswillbeoversoon.Icandoit. Thisfearmayslowmedown,butIwillnotbeincapacitatedbyit. Imayfeelnauseatedandwanttoavoidthesituation,butIcandealwithit. ReinforcingSelfStatements: ItwasmucheasierthanIthought. IdiditIgotthroughit,eachtimeitwillbeeasier. WhenImanagethethoughtsinmyhead,Icanmanagemywholebody. I'mavoidingthingslessandless.I'mmakingprogress. Onestepatatimeeasydoesit.Nothingsucceedslikesuccess.

Readtheexamplescarefullyandworkoutafewselfstatementsthatyoufeelcomfortable with.Thenwritethemonacardthatyoucancarrywithyousothatit'shandywhenyouneedit. Whenyouknowyouareabouttodosomethingdifficult,it'sagoodideatosetasidesometimeto preparespecificcardsfortheoccasion.Forexample,ifyouaregoingintothecity,youmaywrite somethinglikethisonasmallcardthatyoucancarrywithyou: It'snaturaltobenervousaboutgoingintothecitygivenmytraumatic experiences,butthelikelihoodofanythingbadhappeningisveryremote.Just relaxandslowdownmybreathing.Imaynotfeelgreat,butIcancope.Now, whatisitthatIneedtodo? Likeeverythingelse,themoreyoupracticeusingtheseselfstatements,themoreeffective theywillbeinhelpingyoutomanageyouranxietyatdifficulttimes.Thiswillbecomeespecially
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importantaswemoveontothenextstageoftreatment. 4.6ChangingBehaviours Aswenotedabove,onefeatureofPTSDisthatpeopleloseinterestinnormalactivitiesand withdrawintothemselves,cuttingofffromfriendsandthingstheyusedtoenjoy.Thisisaparticular difficultyifyouarenotworking.Itisimportanttoaddressthisproblemdirectly,evenifyoudonot feellikeit.Doingnothingprovideslotsofopportunitiesforthememoriestocomebackandisasure wayofmakingyoufeeldepressedandanxious. Whenyougetupinthemorning(orthenightbefore),makeaplanofwhatyouwilldothat day.Takeasheetofpaperandwritedownthehours(say,from9.00amto9.00pm)onthelefthand side.Thenfillineachhourwithwhatyouintendtodo.Ifyouareworking,thatwilltakeupmuchof theday.Ifnot,youwillneedtotrytofindworthwhileactivitiestotakeupyourtime.Havingsome structureandroutinetoyourdaywilldoagreatdealtohelpyoufeelmoreincontrol.Trytoputina broadrangeofactivitiesbutdonotexpecttoomuchofyourself. Possibleactivitiesforyourdailytimetable: Someexercise:walk,swim,cycleride,gym Somework:jobsaroundthehouse,study,chores,voluntarywork Somethingforfun:amovie,museum,artgallery,zoo,windowshopping Somesocialactivities:visitfriends,meetsomeoneforcoffee,acluborsociety Someanxietymanagementpractice:relaxation,breathing,selfstatements Sometimeforothertherapyhomework

4.7Arousalandanger Thestrategiesaboveareimportantinhelpingyoudealwithangeraswellasanxiety.Anger oftenactsasastumblingblocktorecovery,preventingyoufrommovingontothenextstageof


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treatment.Thephysicalaspectsoftensionandhigharousalaresimilarinbothanxietyandanger,but thetriggersthatsetoffthefeelingswilloftenbedifferent.Trytoidentifythekindsofsituationsthat leadyoutobecomeangrythefirststepinmanagingyourangerisbeingpreparedforit.Takeasheet ofpaperandjotdownalistofthingsthatarelikelytosetyouoff.Amajordifficultywithangeristhat itescalatessoquicklythatitbecomesveryhardtocontrol.Ifyoucanrecognisethewarningsignsand interveneearly,youwillhaveamuchbetterchanceofdoingsomethingaboutit.Thinkbacktothe lasttimethatyouwereangryandjotdownalistofthefirstsignsthatappeared.(Whathappenedto youphysically?Whathappenedtoyourthoughts?Whathappenedtoyourbehaviour?).Onceyouare moreawareofthetriggersandtheearlywarningsigns,youwillbeinamuchbetterpositiontouse thestrategiesdescribedabovetocontrolyouranger. Wewillbrieflylookatthreeextrastrategiesthatpeoplefindusefulfordealingwithangerin PTSD.Theyareallcommonsense,butcanbeveryeffective: Delay:Aswesaid,angerescalatesveryquicklysoyouneedtofindawaytostopyourself makingthatfirstangryresponse.Takeafewslow,easybreathsandcounttotenbefore youreact. TimeOut:Ifyoufeeltheangerbeginningtoescalate,trytoremoveyourselffromthe situation.Thisdoesnotmeanstormingoutinarage.Itmeansexplainingtotheperson youarewiththatyouarenotthinkingtooclearlyandthatyouneedafiveminutebreak. Gooutsideorintoanotherroomandusesomeofthestrategiesdescribedabovetocalm down.Thengobackandtryagain. Planning:Onceyouhaveidentifiedthetriggers,itisimportanttousethatinformationto prepareyourselfforhighrisksituations.Ifyouaregoingtodosomethingthatyouknowis likelytomakeyouangry,chooseagoodmoment(e.g.,nootherdistractions,nottootired orhungry,plentyoftime).Practicewhatyouwilldoorsayinyourheadbeforehand.
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Section5 5.ExposureTherapy:ConfrontingFearedSituations Thenextpartoftreatmentisthemostdifficultandpainfulconfrontingthefearedsituations andtraumaticmemories.Itisalsothemostimportant.Yourtherapistwillnotstartthisprocessuntil youarereadyandwilltakeyouthroughatapacethatyoucanmanage.Mostpeoplefindthatitisnot nearlyasdifficultastheyexpectittobeandthereisoftenatremendoussenseofreliefand achievementasthefearedsituationsandpainfulmemoriesareconfrontedanddealtwith. Notsurprisingly,anxietyfrequentlycausespeopletostayawayfromfrighteningsituations.It isquitenormalforpeopletowanttoescapeoravoidsituations,thoughts,memories,orfeelingsthat arepainfulordistressing.However,thisisoneofthemajorimpedimentstorecovery.Avoidanceand escapeprovidetemporaryrelieftheanxietyreducesbutthenexttimethepersonencountersthat situationagain,heorsheislikelytobecomeanxiouslongbeforeitisplannedtooccur.Wecallthis "anticipatoryanxiety".Themorethesituationisavoided,themorethepersoncontinuestobelieve thatitisdangerous.Further,evenifthepersondoesnotavoid,theanxietymaycontinuetobuild oncetheyareinthesituation.Veryoftenpeoplebelievethatiftheydonotleavethesituationthey will"losecontrol",gocrazy,haveaheartattack,orhavesomeotherdireconsequences.Atthe veryleast,theyarelikelytobelievethattheunpleasantfeelingswillbeintolerable.Exposuretherapy aimstoshowthatthisisnotthecasebyhelpingthepersontoconfrontthefearedsituation.The importantthingtorememberwhenyouareconfrontingsomethingthatyouarefrightenedof (whetheritisasituationoramemory)isthattheanxietywillcomedownifyoustaytherelong enough.Thereisnoanswertothequestionofhowlongisenough.Insomecases,theanxietymay dropconsiderablyin1520minutes.Inothercases,itmaytakeaslongasanhourormorebutitwill reduceeventually.Itisvitalthatyoutrytostayinthefearedsituationlongenoughfortheanxietyto
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reduce.Itisimportanttonotealsothatanxietyoftenincreasesbeforeitstartstodrop.This temporaryincreaseisoftenenoughtomakepeopleavoidorescapeitisvitalthatyoustaywiththe fearedsituationthroughthisphaseuntiltheanxietyreduces.ThispatternisshowninFigure2.You willnoticethatthedropinanxietyisnotsmoothyoumaynoticeoccasionalsmallincreasesbutthe generaltrendisdownwards.Exposureisdoneinacontrolledandgradualfashionsothatdiscomfort iskeptmanageable.Bybuildinguponrepeatedsuccessesinfacingthesefearedsituations,youwill eventuallyabletoconfrontthemwithoutanxietyandnolongeravoidthem.

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100 90 80 Anxiety 70 60 50 40 30 20 10 Figure2: Inmanyways,thisapproachiscommonsense.Let'stakeanexampleofalittleboywhois standingonthebeachwhenabigwaveknockshimover.Hebecomesveryfrightenedoftheseaand refusestogotothebeachthenextday.Howwouldhismotherorfatherhelp?Inordertoovercome


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Time

Anxietyreductionduringexposure

thefear,hisparentsmaytakehimforawalkalongthebeach,stayingawayfromthesea,holdinghis handandreassuringhim.Gradually,theywalkcloserandclosertothewater'sedge.Eventually,the boyisabletogointotheseaagainunaided.Thisisasimpleexample,butexactlythesameprocess appliestotreatingmoresevereandcomplexfearsinadults. Thissectiondiscussesconfrontingactivities,places,people,orobjectsthatyouhavebecome frightenedofsincethetrauma.Wecallthistypeofexposure"invivo".Invivosimplymeans"inreal life".Whenweareconfrontingmemories,wehavetodoitinimagination,sowecallitimaginal exposurethatisdiscussedinthenextsection.Inconductingexposuretreatment,yourtherapistwill workwithyouinconstructingahierarchyalistoffearedsituationsinorderofdifficulty.Treatment involvestacklingeachitem,oneatatime,andmovingontothenextonlywhenyouareconfidentto doso.Moredifficultitemsmaybebrokenupintoseveralsteps.Exposuretreatmentcanbedifficult andpainful,butitisthemosteffectivewayoftreatingmanyanxieties. 5.1PlanningYourProgram 1. Drawupalistofgoalsthatyouwouldliketoachieve.Thesearelikelytocompriseplacesand activitiesthatyouhaveavoidedsincethetrauma.Thegoalsshouldbeveryspecificandshould varyfromrelativelyeasytoextremelydifficult.Don'tworryiftheworstonesseemunachievable atthemomenttheywillbecomeeasierasyouprogressthroughtheothers.Listtheminorderof difficulty,startingwiththeeasiest.Forexample: Tobeabletogoshoppingatthelocalshoppingcentre Tobeabletocatchpublictransportintothecity Togobacktowherethetraumaoccurred

Asageneralrule,asyouworkthroughthelistyoushouldbeaimingtoconfrontsituations thatproduceaSUDSlevelofaround70.Forthefirstoneortwo,however,wesuggestthatyoustart

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withonesthatarealittleeasierthanthat(say,around50)itisimportantthatyouexperiencesome successearlyonintheprocess. 2. Ifsomethingistoohardtotryinonego,breakitdownintosmallersteps.Forexample,ifyou wereassaultedinaparticularpark,thefirststepmaybetogototheendofthestreetandlookat theparkfromadistance.Thesecondmaybetogototheedgeofthepark;thethirdtowalkinto theparkashortdistance;andthefinalonetogobacktothespotwheretheassaultoccurred. 3. Youmaywanttoworkonmorethanoneitematanyonetime,butdonotoverwhelmyourself. Whenyouhavemasteredone(thatis,youareabletodoitwithminimalanxiety),moveontothe nextmoredifficultone. 5.2ImplementingYourProgram 1. Trytodoatleastoneofyourselectedgoalseveryday.Avoidingsomethingonedaywillsetyou back,asyouwillhavebuiltupthefearyouaretryingtoreduce.Sometimesyouwillhavebad daysandfeelthatyouarenotprogressing.Itisimportanttostilldosomething,althoughyoumay choosetojustgooverstepsthatyouhavealreadymastered. 2. Youwillneedtodoeachstepseveraltimesuntilyoumasterit.Onceyoucandoitwithouttoo muchanxiety,itisstillimportanttodoitonceinawhiletomakesureyoudon'tslipback.The generalruleis:themoreyoufearit,themorefrequentlyyouneedtoconfrontit. 3. Keepacarefulrecordofyourprogress.Takeasheetofpaperanddivideitintocolumns.Inthe first,writedownyourgoal.Inthesecond,notethedate.Inthethirdandfourth,writethetime youstartedand(whenyougetback)thetimeyoufinished.Inthefifth,writedownthemaximum SUDSyoureachedandinthesixththeSUDSlevelwhenyouleftthesituation.Thefinalcolumn shouldbeusedformakinganycommentsabouttheexercise.Thiswillhelpbothyouandyour therapistkeeptrackofyourexposureprogress.

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5.3PracticingTheSteps 1. Trytorelaxusingthetechniquesdescribedabovebeforeyoustart.Getyourselfascalmas possible. 2. Mentallyrehearsetheactivity.Gothroughitinyourmindandworkoutstrategiestodealwith difficultaspects.Practicethecopingselfstatementsthatyouwillsaytoyourselfwhenyou becomedistressed.Goodpreparationwillmakesuccessmorelikely. 3. 4. Goabouttheexerciseinaslowandrelaxedmannergiveyourselfplentyoftime. KeepaneyeonyourSUDSthroughouttheexercise.Iftheybecomeveryhigh(80ormore)before you'vereachedyourgoal,stopandwaitforawhileuntiltheanxietycomesdownabit.When youfeelready,moveonagainslowly. 5. Trytostayinthesituationuntilyoufeelyourselfcalmingdown.Ideally,theSUDSshouldreduce byhalf(e.g.,from70to35).Thelongeryouremaininthesituation,thecalmeryouwillbecome andthefasteryouwillovercomeyourfears. 6. Neverleavethesituationwhileyouranxietyisstillhigh.Trytofacethefear,acceptit,letitfade away,andtheneithermoveonorreturn.Ifyouleavewhiletheanxietyisstillhighitwillbemore difficultnexttime.Remindyourselfthatyouhavedonereallywelltogetthisfar;justhangin thereuntiltheanxietycomesdown. 7. Congratulateyourselfforyourachievements.Thisisveryhardworkandyoudeserveapatonthe back.Don'tputyourselfdownbysayingthatyoucoulddothiskindofthingeasilybeforethe traumaorthatanyoneshouldbeabletodoitwithoutgettingupset.It'savitalpartofyour recovery.

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Section6 6.ExposureTherapy:ConfrontingTheMemories Aformofexposuretherapyisalsousedtotreatdistressingmemoriesofthetrauma.Wecallit "imaginalexposure".Insection5,wetalkedaboutconfrontingfearedsituationssuchasplaces, people,andactivities.IncasesofPTSD,however,themost"fearedsituation"isactuallythepainful memoriesofyourexperience.Thesememoriesaresofrightening,andcausesomuchdistress,that thepersontriestoavoidorescapefromthembyblockingthemout.Imaginalexposuretreatments areusedtoassistinconfrontingthememories.Exposureisonlyonetermusedtodescribethis process.Somepeopletalkabout"traumafocuswork","workingthroughthetrauma","comingto termswiththeexperience"orsimply"confrontingthememories". 6.1WhatIsImaginalExposure? TherearemanyanalogiesusedtoexplainthisprocesstoPTSDsufferersbeforetreatment commences.Thefollowingexamplesmayhelpyoutounderstandwhatwillhappenandwhyitis important. After a trauma, we often try to file away our memory of what happened,puttingittothebackofourmind.It'sasifwearetryingtopack theeventawayintoabox.Wethenusealittlestrengthtokeepthelidtightly closed and try to leave it undisturbed. However, over time, two things happen.Firstly,ourstrengthbeginstowaneanditbecomesmoreofaneffort tokeepitsealed(thatis,tostopthememoriesfromcomingback).Secondly, duetothepressure,theboxbeginstoloseitsshapeandsmallcracksbeginto appear.Whatweexperienceassymptoms(suchasmemoriesofthetrauma, and having nightmares and disturbed sleep) is like the content of the box
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spillingoutthroughthesecracks.Thisisusuallyveryfrightening,sowetryto avoid anything that reminds us of the trauma. We try to stop thinking and talkingaboutwhathappenedandhowwefelt.Inthisway,thecontentofthe box becomes a ghost which we have learned to fear and which we are terrifiedofconfronting.Aspartoftherapy,wearegoingtoopentheboxand inspectthecontentforwhatitreallyis.Wewilltalkthroughwhathappened andhowyoufelt.Wewillbeinspectingtheghoststhathavebeencreated 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 mannerthesymptomsbecomemuchlesssevereandlessfrequent. Anotheranalogytalksaboutthedentist: "When dentists work on a decayed tooth, they don't just slap the filling on top of the decay. If they did, it may be fine for a few weeks or months,buttheproblemswouldkeepcomingbackasthetoothcontinuedto deteriorate.Instead,theyspendsometimedrillingandscraping,cleaningout allthedecaybeforeputtingthetoothbacktogether.Thisisaveryunpleasant andpainful process, butwe knowitisworthgoingthrough this shortterm painforthelongtermgain.Traumaticmemoriesareabitliketoothdecay. We need to make sure that we have confronted all aspects of the trauma beforewetrytoputtheeventbehindus.Weneedtogiveourselvestimeto face up to even the worst parts of the experience so that there are no skeletonsintheclosettocomeandhauntusinthefuture.Likethedentist's drilling,itisapainfulprocessbutanimportantpartofrecovery". AfinalanalogycomesfromtheworkofEdnaFoa,oneoftheleadingexpertsinthetreatment
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ofPTSD: "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 hasnotbeenadequatelydigested.Treatmentwillhelpyoutostartdigesting yourheavymemoriessothattheywillstopinterferingwithyourdailylife". Exposurebasedtreatmentsarenotforeverybody.Insomecases,ifthetraumaoccurred manyyearsagoandthememoriesarenotcausingtoomuchofaproblem,itmaybebestnottodrag everythingupagain.Talktoyourtherapistaboutwhetherthisapproachwouldbebeneficialforyou. 6.2TherapistAssistedImaginalExposure Confrontingthetraumaticmemoriesisaverydifficultandpainfulprocess,andisbestdone withthehelpofanexperiencedtherapist.Thereareseveralstepsthatyourtherapistwilltakeyou through.First,thetherapistwillprovideanexplanationoftheprocess,includingwhatyouwillbe doing,whyyouaredoingit,andareminderontheSUDSscale,aswellasansweringanyquestions youmayhave.Next,thetherapistwillworkwithyoutodevelopahierarchyofpainfulmemoriesin muchthesamewayasyoudevelopedalistofgoalsforyourinvivoexposureabove.Ifyouhave experiencedseveraltraumaticevents,thismaybesimpleenough.Youwillneedtothinkabouteach eventandranktheminorderofhowdistressingtheyareforyoutoremember.Ifyouhaveonly experiencedoneeventthatiscausingyouproblems,youwillnotneedtogenerateahierarchy. Thetherapistwillthenaskyoutogothroughtheselectedeventorexperienceingreatdetail, startingatthebeginningandcontinuingthroughtotheend,toapointwhereyoufeltrelativelysafe. Inordertokeepthedistressmanageable,youmayinitiallybeallowedtokeepyoureyesopen,totalk inthepasttense(e.g,"IwaswalkingalongthepathwhenIsawhimcomingtowardsme"),andtoskip
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someoftheworstdetails.Fortheproceduretobefullyeffective,however,youwillneedtobuildup (perhapsoverseveralsessions)tomakingyouraccountasvividanddetailedaspossible.Youwill needtotalkthroughthewholeeventwithyoureyesclosedandinthepresenttense(e.g.,"Iam walkingalongthepathandIcanseehimcomingtowardsme"),sincethismakesitmuchmorereal foryou.Youwillneedtobecarefulthatyoudonotmissanyofthedetails,even(orperhaps especially)theworstones.Rememberthatwedonotwanttoleaveanyskeletonsintheclosetto comeoutandworryyouinthefuture.Yourtherapistwillrepeatthisprocessmanytimesinthesame sessionand/orinsubsequentsessions.However,themoreoftenyougothroughitthequickeryou willrecover,soyourtherapistmaytapethesessionandaskyoutolistentothetapeeverydayat home.Again,thisisnotaneasyprocess,butstickingtothefollowingstepswillhelpyouthroughit andhelptoensurethatitprovidesthemaximumbenefit. Step1:Preparation Plananactivitytodoimmediatelyafterwards:(e.g.,goforawalk,visitorringafriend,doan enjoyableabsorbingactivity;notanaddictiveactivitylikewatchingTVordrinking,oran emotionalshutdownlikehidingawayonyourown) Chooseaprivateplacewithnointerruptions(takethephoneoffthehook,letothersknowyou arenottobedisturbed) Identifytwopeopleyoucancontactimmediatelyifyouneedhelp:keeptheirphonenumbers handy Brieflyrelaxyourselfandtrytoclearyourmindofotherthoughtsandworries:notedownyour SUDSlevelonapieceofpaper Step2:Confrontthememorysafely Listentothetapeandtrytofocusonwhatisbeingsaid:trynottoimagineother,more frighteningpartsjustconcentrateonthetape
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Equally,trytoimagineithappeningasifyouwereexperiencingitagain:Whatcanyousee,hear, smell,touch,taste?Whatareyoufeelingandthinking?

Whenremindedtodosoonthetape,noteyourSUDSlevel.Iftheyareabove90,takeamoment toremindyourselfwhereyouare;youaresafehereandnow;youcanfeelasupsetasyouneed tointhememory

Don'tstopthetapeinthemiddle:stickwiththememorythroughtotheend

Step3:Attheendofthetape,pauseandopenyoureyes Lookaround,feelthechair,remindyourselfwhereyouareandthatyouaresafe NoteyourSUDSlevelanduseanarousalmanagementstrategyifnecessary(suchasbreathing controlorrelaxation) Step4:Processthememorybywritingdownsomeorallof: Whatnew(orold)piecesofthememorydidyoudiscoverorbecameclearer? Areyounowthinkingdifferentlyaboutanyaspects? Whatfeelingsorthoughtsaregoingthroughyourmindrightnow? Whatpartsofthememoryarestilltooupsettingtorememberoraccept? Whatdoyoustillwanttochangeabouttheeventoritsaftermath?Howcanyouachievethat? Whatdidyoudothatyoushouldbeabletofeelgoodabout?

Step5:Relaxanddoyourplannedactivity 6.3SelfDirectedImaginalExposure Manypeoplefinditdifficulttodoimaginalexposuretotraumaticmemoriesontheirown.The processistoopainfulandtheyneedthesupportandstructureprovidedbyatherapist.However,itis notimpossible.Indeed,manypeoplewhorecoverfromtraumawithoutprofessionalhelparedoing justthat.Theyarethinkingaboutthetraumaoftenenough,forlongenough,andinenoughdetailfor


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thememorytolosetheworstofitsassociateddistressandforittobecomemodifiedand"sorted out"intheirownmind.Ifyouaregoingtoattempttheprocesswithoutatherapist,writingdownthe memoryisoftenausefulwayofdoingit.(Indeed,itmaybehelpfultodothisevenifyouareworking withatherapist,althoughwesuggestthatyoudiscussitwiththemfirst). Theassignmentdescribedbelow(andtheoneappearinginthenextsection)isadaptedfrom theworkoftwoAmericanpsychologists,PatriciaResickandMonicaSchnicke.Followthesteps outlinedintheprevioussectionwhendoingthetask(substitutingthewritingforlisteningtothe tape).Makesureyoureadthroughthosestepscarefullyandprepareyourselfproperlybefore attemptingtheassignment.Selectasuitabletimeandplacesothatyouhaveenoughprivacyand sufficienttimetodothetaskproperly. Thistaskisimportantinhelpingyoutosortoutexactlywhathappened.Theprocessof "puttingthepiecesofthejigsawpuzzletogether"seemstobeveryimportantingettingoverthe incident.Italsoworksinasimilarwaytotheimaginalexposuredescribedabovethemoreyou confrontthepainfulmemoriesandthebadfeelingsassociatedwiththem,thelesspowerfuland distressingtheywillbecome. Thetaskistotakeasheetofpaperanexercisebookwouldbeidealandwriteouta detailedaccountofexactlywhathappened.(Interestingly,researchsuggeststhatitismuchmore effectiveifyouwriteitoutbyhandratherthanusingawordprocessor).Includeasmanysensory detailsaspossible(sights,sounds,smells,andsoon).Alsotrytoincludeallthethoughtsandfeelings thatyouhadduringtheevent.Donotstopyourselffromfeelingtheemotionsalthoughitispainful, thatispartoftherecoveryprocess.Ifyoubecometoodistressed,youcanstopwritingforawhilebut trytocontinueagainassoonaspossible.Itisimportanttokeepwritinguntilyoureachtheend(anda pointofrelativesafety),evenifthattakesalongwhile.MakeanoteofyourSUDSlevelinthemargin everyfewminutesthisisimportanttocompareyourlevelswhenyourereadorrewritethe
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account.Youcanrewritetheaccountasoftenasyoulike,puttinginmoredetailsordifferent perspectivesastheycometoyou.Ondayswhenyoudonotrewritetheaccount,readittoyourself atleastonce.Again,sticktothestepsoutlinedabovewhenyoudothis.Ifyouhavekeptanoteofthe SUDSlevelsinthemargin,youwillnoticethemdroppingovertimeasyourepeattheprocess.You willneedtorepeatthetaskuntilyourSUDSarereasonablylowthroughout(say,amaximumofabout 30). 6.4Exposure:CanICopeWithIt? Exposureisaverydifficultandpainfulprocess,butitistheonlywaytorecovery.Aswenoted above,itisusuallynotasdifficultasyoufearitwillbeandmostpeoplegetanenormoussenseof achievementwhentheyhaveconfrontedthememoryorotherfearedsituation.Ifyouhaveread(and practiced)thesectionsabove,younowhaveseveralstrategiesthatwillhelpyoumanageyouranxiety anddistress.Theseareveryusefultousebothbeforeandaftertheexposureexercises.Ifnecessary, youcanusethemduringtheexposureexercisesalso,althoughwerecommendthatyouonlydothis ifyoureallyneedto.Itisbettertoconfrontthefullanxietyandallowittoreduceofitsownaccord thatitistouseotherstrategiestobringitdown.However,itisimportantthatyoudonotfeel overwhelmedatanytime.Despitethebestofintentions(intermsofpreparingyourhierarchiesand onlyconfrontingsituationsormemoriesthatyoufeelreadyfor)theanxietywill,sometimes,be greaterthanyouexpect.Onthoseoccasions,byallmeansuseyourcopingstrategiesifnecessary.

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Section7 7.CognitiveRestructuring Oneeffectthatexposuremayhaveistobringtothesurfaceunhelpfulthoughtsandbeliefs thathavearisenasaresultofyourexperiences.Inordertorecovereffectivelyfromthetrauma,it maybenecessarytochallengethosethoughtsandbeliefs(wecallthem"cognitions"),andtryto replacethemwithsomethingmorerationalandrealistic.InPTSD,thisprocessisbestcarriedoutin conjunctionwiththeprocessofexposure,modifyingtheunhelpfulcognitionsastheyarise. Followingatraumaticexperience,peoplemaybeleftwitharangeofnegativethoughtsabout whathappened,aswellasaboutthemselvesandtheworld.Forexample,manypeopleareleft feelingvulnerableandinsecure.Theymaythinkthattheworldhasbecomeadangerousplaceand thatotherpeoplearenasty,cruel,andouttotakeadvantage.Similarly,manypeopleexperience feelingsofguiltandshamefollowingtrauma.Theymaythinkthattheyarebadorevilforactinginthe waytheydidduringoraftertheincident;theymaythinkthatwhathappenedwastheirfault;they mayseethemselvesasweakorinadequatefornotcopingbetter.Sometimes,theremaybeelements oftruthinthesethoughts.Usually,however,theyarecompletelyuntrueor,atleast,grossly exaggerated.Thiskindofthinkingleadstoallsortsofunpleasantemotionssuchasdepressionand guilt,anxietyandfear,andanger.Animportantpartofrecoveryinvolvesidentifyingthose maladaptivethoughts,challengingthem,andreplacingthemwithamorerealisticviewofyourself andtheworld. Cognitiverestructuringisaprocedurewherebypeoplesthoughts,beliefsandinterpretations aboutpastexperiencesareidentifiedandmistakesinthinkingarehighlighted.Forexample,itmaybe thatthepersonisthinkingin"blackandwhiteterms"seeingthings(orotherpeople)asallgoodor allbadwheninrealitytheworldholdsmuchthatis"grey".Itmaynotbeperfect,butit'snotallbad
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either.Thepersonmaybeovergeneralising(e.g.,noonecanbetrusted)oroverfocussingonthe negativesandminimisingthepositivesabouttheirsituation.Theymayseeonenegativethingas confirmationthattheyarenotcoping,whileignoringotherevidencethattheyare,infact,coping quitewell.AcommonprobleminPTSDisthatpeoplebasetheirinterpretationsaboutwhat happened,themselves,ortheworldupononlyafragmentofthememory(thepartthatrepeatedly comesback)ratherthanoninformationthatplacesthataspectinabroadercontext.Oncethese faultythoughtpatternsarediscovered,itisthegoalofcognitivetherapytoreplacethemwithmore adaptive,realisticandflexiblebeliefs.This,ofcourse,includesreevaluatingourexperiencesand,in particular,thetraumaticevent.Itisadifficultprocessthatcantakealotofhardwork,butitcanbe veryeffectiveinminimisingandmanagingunpleasantemotions. 7.1TheProcessofCognitiveRestructuring Aswithseveralothercomponentsoftreatment,theotherpatientmanualsinthisbook containsomeexcellentdescriptionsoftheprocessofcognitiverestructuring.Ifyouareworkingwith atherapist,youmaywishtoaskhimorhertocopysomeoftherelevantsectionsforyou.Inthis section,wewilltalkbrieflyabouthowtogoaboutidentifyingandchallengingyourunhelpful thoughtswithspecificreferencetotrauma.Agoodstartingpointistodoanotherassignmentthis onefollowsonwellfromtheexercisediscussedinsection7.3above. Thetaskthistimeistowriteatleastonepageonwhatyourexperienceoftheeventmeansto you.Inparticular,howhasitchangedyourbeliefs,views,andideasaboutyourself,otherpeople,and theworld?Whatviewsorbeliefshavebeenstrengthened?Whichoneshavechanged?Trytowrite somethingundereachofthefollowingheadings: Mybeliefsaboutmyselfhavechangedsincethetraumainthefollowingways Mybeliefsaboutotherpeoplehavechangedsincethetraumainthefollowingways

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Mybeliefsabouttheworldhavechangedsincethetraumainthefollowingways Inansweringthosequestions,youmaywanttothinkaboutissueslikehowyoufeelabout

yourself(selfesteem),yourpersonalsafety,trustingothers,thoughtsaboutcontrolandpower, intimacywithothers,whatkindofsocietywelivein,etc.Anywaysinwhichyouthinktheeventhas changedyourideas,thoughtsandbeliefs. Thenextstageistopickoneofthekeythemesthatisleadingyoutofeelanunpleasant emotion.Whichonemakesyoufeelangry?Orfrightened?Orguilty?Orsad?Trytoexpressitasa singlestatementofopinion,suchas"allmenarebad"or"itwasallmyfault".Inparticular,lookfor statementsbeginningwith"I",suchas"I'mweakandhopeless"or"I'mnotsafeanywhere".Write thisthoughtorbeliefatthetopofacleansheetinyourexercisebook.Thengothroughandtryto answerthefollowingquestions.Someofthemmaynotapplytoeverythought,butmostwillthey willhelpyoutoreevaluatewhetheryourthoughtsandbeliefsarereallytrue. Whatistheevidence?Herewewantyoutobecomeascientistandreallythinkaboutthe objectiveevidenceforandagainstthethought.Isitreallytrue?Areyou100%sure?Dothefactsof thesituationbackupwhatyouthinkorcontradictit?Writeoutalltheevidenceyoucanthinkoffor andagainstthethought.Inmostcases,youwillfindthatitisnotcompletelytrue.(Indeed,itmayturn outtobecompletelyfalse). Whatalternativeviewsarethere?Howdootherpeoplethinkaboutthis?Wouldother peopleagreewithyou?Isthereanotherwayoflookingatit?Arethereotherexplanations?Tryto generateasmanyalternativeexplanationsasyoucanandreviewtheevidenceforandagainstthem. Whenyoulookatitobjectively,whichexplanationismostlikelytobecorrect? AmIthinkinginallornothing,blackandwhiteterms?AmIusingtermslikeall,always, never?Nothingisallbadorallgood,nopersoniseitherperfectorworthless.Trytolookforamore balancedview,withamorerealisticassessmentofthesituation.
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AmIoverestimatingmyresponsibility?Thingshappenforallsortsofcomplexreasons,many ofwhichwemayneverunderstand.Beverycarefulnottotaketoomuchresponsibilityforthings overwhichyoudonothavecontrol. AremyjudgementsbasedonhowIfeel,ratherthanwhatisactuallyhappening?Ifyoufeel guilty,youarelikelytoassumethingsmusthavebeenyourfault.Ifyoufeelfrightened,youmay assumethatyouarenotsafe.Ifyoufeeldepressed,youmayassumethatthingswillnevergetbetter. Feelingsarenotagoodbasisonwhichtomakerationaljudgements.Putthefeelingstoonesidefora momentandlookforobjectiveevidence. AmIoverfocussingononeaspectandforgettingotheraspects?AmIlookingonlyatthe negativesideandignoringtheneutralorpositivethings?Ifwefocusonlyonsmallpartsofthewhole picture,wewillendupwithaverydistortedviewofreality. Howlikelyisit?AmIconfusingalowprobabilitywithahighprobability?Howlikelyisitthat whatyoufearwillactuallyhappen?Understandably,manytraumasurvivorsfeararecurrenceofthe eventbut,realistically,howlikelyisit? AmIunderestimatingwhatIcandoaboutit?AmIputtingmyselfintheroleofhelpless victim?WhatcanIdotomakethingsbetterorsaferformyself?Takingsomecontroldoing somethingaboutitisanimportantpartofrecovery. WhatwillhappenifIcontinuetothinklikethis?Isthiskindofthinkinghelpingmeto recover?Willithelpmetoliveahappyandrelaxedlife?Arethereanybenefitstothinkingthisway? Ifnot,itisworthworkinghardtotryandletgooftheirrationalnegativethoughts. Whenyouhavewrittenananswertoall(ormost)oftheabovequestions,gobackand reconsidertheoriginalthought.Doyoustillbelieveit?Isitstillarationalstatementofreality?Ifyes, trytogothroughtheaboveprocessagaintalkingtootherswhocanbemoreobjectivemayhelp.Do notexpectallthenegativethoughtstodisappearatonceitishardworkandyouwillneedtogo
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throughtheprocessmanytimestoshiftthoseideas.Ifthethoughtdoesnotseementirelyrational now,canyoucomeupwithamorerealisticversionoftheoriginalthought?Rememberthatweare nottalkinghereaboutpositivethinkingthatisjustasunrealisticandveryfragile.Wedonotwantto pretendthateverythingisrosywhenitisnot.Wedonotwanttominimisewhatyouwentthrough. Equally,wedonotwanttooveremphasisethenegatives.Recoveryisdifficult,butyoucanmake progress;lifewillnotalwaysbesafe,butdonotexaggeratethedangers.Forexample,iftheoriginal thoughtwas"allmenarebad",amorerationalalternativemaybe"somemenarebad,butbyno meansallmostmenareactuallycaring,safe,friendlypeople".Iftheoriginalthoughtwas"I'mnot safeanywhere"therationalalternativemaybe"IamsafeinmostplacesmostofthetimeIwillbe carefulnottoputmyselfindangeroussituations,butIdonotneedtoworryconstantlyaboutgetting hurtagain".

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Section8 8.RelapsePrevention Thefinalstageoftreatmentwilllookatrelapseprevention.Recoveryisnotjustaboutgetting better,itisaboutstayingbetter.Somesimplestrategieswillhelpyougetthroughdifficulttimesin thefuture.Thereareafewsimplepointstorememberinrelapseprevention: Lapsesaretobeexpectedfromtimetotime:Whenyouareremindedofyourtraumatic experience(suchashearingofasimilarevent,orexperiencingsomethingelsefrightening)itis naturalforyoutobecomealittledistressed.Thisispartofanormalhumanreactionand,aslong asitisnottoosevereorlaststoolong,youshouldnotconsiderittobeaproblem.Youcancope withbeingupsetforawhile.Itbecomesaproblemifyouarenotexpectingitandyoutellyourself thatyouhave"falleninaheap"orthatyouare"backtosquareone".Simplyuseitasareminder topracticeyourcopingstrategiesabitmoreforafewdays. Beawareoftheearlywarningsigns:Keepaneyeonyourselfandtrytonoticewhenyouarenot copingsowell.Theearlythatyoucanrecognisethatthingsarenotright,theeasieritwillbetodo somethingaboutit.Thelongeryouleaveit,theworseitwillget,andthemoredifficultitwill becometopullyourselfoutagain.Itwillbeeasiertorecognisetheearlywarningsignsifyouare awareofthekindofthingsthatmayprecipitatealapse. Identifyhighrisksituations:Spendsometimethinkingaboutwhatkindsofthingsmaycauseyou tobecomeupsetthemorepreparedyouare,thebetteryouwillcope.Thekindsofthingsthat upsetmosttraumasurvivorsarepowerfulremindersornewsofsimilarincidents;anexperience similartotheoriginaltrauma;andotherlifestressessuchasfinancialorfamilyproblems.What kindsofthingsmaycauseyoutobecomeupsetandthinkaboutthetraumaagain? Generateaplantocope:Writedownonacardwhatyouwilldoifandwhenyouareupsetagain
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aboutthetrauma.Thekindsofthingstoincludeare: Whowillyoucall?Writedownthenamesandphonenumbers Physicalcopingstrategies:Whicharousalmanagementstrategiesworkedbestforyou? Writedownoneortwo(suchasbreathingcontrol,goforawalk,listentotherelaxation tape)asaremindertodothem Cognitivecopingstrategies:Writeoutacopingselfstatementthatyoucanusesuchas"I expecttofeelupsetwhenI'mremindedofwhathappened,butthat'sOKImaynotlikeit butIcancopewithit.Idon'thavetomakeitworsebyexaggeratingit.Now,whatcanIdo tomakemyselffeelbetter?"Youmaywishalsotojotdownanyotherstrategiesthat workedwellforyousuchasyourfavouritedistractiontechniqueorthoughtstopping Behaviouralcopingstrategies:Writedownoneortwothingsyoucandotogetyouback ontrackvisitafriend,gotoamovie,getinvolvedinanengrossinghobbyortask Bepositive:Remindyourselfthatyouexpectedthisfromtimetotimeandthatyouwillgetoverit quickly.Trytoviewitasanopportunitytopracticeyourskillsandbecomeastrongerperson Getprofessionalhelpifnecessary:Nomatterhowwellyouhaverecoveredfromtheoriginal trauma,sometimesarelapsemaybejusttoomuchforyoutocopewithalone.Don'thesitateto getsomeprofessionalhelpifnecessary.Itdoesnotmeanthatyouareweakorthatyouareback tosquareone,simplythatyouneedsomeextrasupporttogetoveradifficulttime.Itmayonly requireoneortwosessions.

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9.ConcludingComments Ifyouhaveworkedyourwaythroughthismanual,withorwithoutatherapist,youwillhave comealongwaytorecoveringfromanexperiencethatchangedyourlife.Aswenotedatthe beginning,youwillneverbequitethesamepersonagain.Butoverthecourseofyourrecoveryyou havelearntmanynewskillsthatwillstandyouingoodsteadinthefuture.Importantly,youhave facedoneoftheworstthingsthatlifecanthrowatyouandyouhavecomethroughit.Youhave survived.Giveyourselfapatonthebackandrememberthat,ifyoucandealwiththis,youcandeal withalmostanything.

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10.RecommendedReading Thefollowingbooksareavailablefrommostlargebookstores,manysmallerones,andsome newsstands.Ifindoubt,askifthebookcanbeordered.Wealsosuggestthatyouuseyourlocal librarytogainaccesstomanyofthesebooks.Whenyoureadtheseoranysimilarbooksonthe managementofanxiety,rememberthattheyarebestregardedasguidelinesonly.Becriticalinboth apositiveandnegativesensewhenreadingthesebooks,sothatyougetwhatisbestforyououtof them.Mostofthesebooksareinexpensive. Allen,J.G.(1999)CopingWithTrauma:AGuideToSelfUnderstanding.WashingtonDC: AmericanPsychiatricPress. Matsakis,A.(1996)ICan'tGetOverIt:AHandbookForTraumaSurvivors(2ndEd).OaklandCA: NewHarbingerPublications. Matsakis,A.(1998)TrustAfterTrauma:AGuideToRelationshipsForSurvivorsAndThoseWho LoveThem.OaklandCA:NewHarbingerPublications. Rosenbloom,D.,Williams,M.B.,&Watkins,B.(1999)LifeAfterTrauma:AWorkbookFor Healing.NewYork:GuilfordPress. Acknowledgement:Partsofthismanualwereadaptedfrom"WhatIsPTSD:Informationfor VeteransandTheirFamilies"writtenbyMarkCreamer,DavidForbes,andGrantDevilly,and producedbytheNationalCentreforWarRelatedPTSD,Melbourne,Australia.

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