Introducing Cognitive Behavioural Therapy (Introducing...) (19 page)

Try this exercise. Set yourself a short time every day over the next few days to write about your experiences, feelings and reactions. You can write about the same thing every day or something different each day. Don’t think too closely about what you write or worry about punctuation, spelling, grammar or even accuracy! Just write. Then get rid of that writing. Don’t re-read it. Throw it away, burn it, recycle it, rip it up – whatever works for you. This exercise is designed to help make sense of and process emotionally charged information, which then helps us to move on and be less affected by stress related to the experiences we have written about. It also might explain why diary keeping has always been so popular.

When do normal reactions to stress become a mental health problem?

It’s a fact that sometimes adverse life events can trigger mental health problems such as anxiety or depression. It’s very difficult for professionals to say exactly where ‘normal’ reactions stop and a mental health problem begins. For some people adjustment to an adverse life event or loss takes a very long time – it may be months or even years before you feel better or able to fully move on with life. In CBT it’s often recommended that people don’t get active or formal treatment in the first few months after a negative life event because distress – even depression and anxiety – is a very normal reaction to an abnormal event in a person’s life. However, it can also be true that some people, for whatever reason, get very stuck following a negative life event and find it impossible to move on or to rebuild their lives.

If you feel that this has happened to you, think first about whether you are perhaps expecting too much, too soon of yourself. Seriously, is it realistic to expect to be ‘over it’ by now? If you do feel you may be depressed or anxious then
Chapter 4
and
Chapter 6
could help you find some ways to tackle this. Talk to people around you. Do they think you are depressed? Sometimes others can judge this much better than we can ourselves. Most importantly, if you feel that things are out of control and the self-help strategies suggested here aren’t working, despite time and practice, then ask for help. What does your GP think?
Chapter 9
outlines the many sources of help available.

Post-Traumatic Stress Disorder (PTSD)

So far in this chapter we have talked about quite common, but difficult and stressful life events. These can feel traumatic, but the traumatic events we are looking at in this section are in a different league. The kind of events which might lead to developing PTSD are ones people believe are life threatening either to themselves or to someone close to them, and that they are helpless to do anything about. Traumatic events, while rare, can happen to anyone. Reading newspaper stories can make one wonder how people cope with situations involving serious injury or death. PTSD arises when the normal responses to an abnormal event:

• Begin within 6 months of the event or period of trauma
  
• Carry on for more than 3 months after this time
  
• Start over 6 months after the trauma – this is called delayed onset PTSD.
  

People experiencing traumatic events feel intense fear, helplessness or horror. Traumatic events are
outside our normal experience
. Divorce, bereavements (except those caused by traumatic events), loss of employment, chronic illness and marital or domestic conflict therefore don’t count as trauma even though, as we have seen, they may be triggers for extreme stress and even anxiety and depression. PTSD has a very particular set of symptoms, different to those of mental health problems, though PTSD sufferers may also have elements of both depression and anxiety. Examples of common traumas that may lead to PTSD are road traffic accidents, attacks or assaults, combat situations and being caught up in natural disasters or acts of terrorism.

Commonly, after a traumatic event most people get some of the following reactions:

• Distressing thoughts, memories, images, dreams or flashbacks of the trauma which keep recurring – sometimes there are blank bits which the person can’t recall
  
• Avoidance; where possible, you try to avoid places, people, activities, thoughts, feelings, conversations or anything else which might trigger memories or thoughts of the trauma
  
• Emotional numbness, detachment from others, difficulty having loving feelings
  
• Seeing the future as hopeless, pointless and likely to be short-lived
  
• Losing interest in and stopping activities you used to enjoy
  
• Increased arousal – you are easily startled and don’t like bright lights or loud noise
  
• Problems sleeping, irritability, anger, difficulty concentrating and increased vigilance.
  

These reactions may be very normal at first and usually pass with time and the use of some good coping strategies. However, for some people, for reasons that we don’t yet fully understand, these symptoms don’t improve and may even worsen over time. Have you gone through a traumatic event and been experiencing any of the feelings above? If they aren’t improving, or are even worsening, you may find the exercises later in this chapter useful. But if things get no better, or even get worse, then it’s very important to seek professional help, either from your doctor, or a qualified mental health professional. Guidance on where to find such help is given in
Chapter 9
.

Why do flashbacks happen?

We don’t know exactly why the brain re-experiences things in the way that it does following trauma. Psychologists believe, however, that it’s to do with the way in which the brain processes events and stores them as memories. Just imagine your memory is like the linen cupboard of a neat, organized housewife (or husband). Each item is first sorted, neatly folded, then put away in an ordered fashion. Sheets go with sheets in one pile, pillow cases are all together in another. When the door is shut, our memories stay locked up inside. When something happens and we choose to open the door, we can take out a memory and examine it or use it. Occasionally things fall off the shelf and out the door at strange or inappropriate times, but generally we can pack stuff away again and it’s no big deal.

Now imagine that along comes a huge, irregularly-shaped duvet which has to be put into the cupboard. It doesn’t fit. It won’t fold into a neat, organized shape and no matter how our heroine (or hero!) tries to pack it away, it just keeps falling back out, forcing the door open. This is what seems to happen with traumatic memories. Our brains initially seem to find it impossible to make sense of or properly process these types of memory – perhaps because they are so far out of our normal experiences and expectations of life. There’s no template to fit them in. It’s as if our brains need to keep re-experiencing the memory in order to try to process it – to pack it away. All the time it’s not processed in the usual way, we experience the event not as a normal memory from the past but as a new event –
just as if it is happening right now
. There is some evidence that the part of the brain which is associated with traumatic memories is the same part connecting to our
flight, fight or freeze
mechanism which we discussed in
Chapter 4
when looking at anxiety. So all our anxiety reactions are triggered each time this event pops up, unbidden, into our minds. Flashbacks can be terrifying, horrible experiences, but they may actually be our brain’s way of trying to heal itself. Fortunately there are ways of lending your brain a helping hand to accomplish this.

What you should
not
do

Quite often people use alcohol or even illicit drugs to try to relax, to help them sleep and to stop thinking about the event. Unfortunately this usually proves at best unsuccessful, and at worst, can increase your problems by adding alcohol or drug dependency to them. If you try to drown your problems with alcohol, chances are they will learn to swim!

What you should do

Let yourself accept the whole array of feelings that you are experiencing. Remind yourself that these are perfectly normal under the circumstances. They don’t mean you are ‘going crazy’, ‘being pathetic’, or any similarly unhelpful name-calling you are doing.

Now look at what you are doing differently compared to before the trauma. Are you over-cautious? If you were attacked, are you now unwilling to leave home after dark, despite living in a safe area? If what you are doing really is excessively cautious compared to before, make a list of the things you are now avoiding and start facing them one at a time, perhaps trying the easiest first. You might even ask a friend or relative to accompany you in the first instance, but then move on to doing it on your own, just as you did before. At first it can be very frightening but as you repeat the actions, and find that nothing awful happens, you’ll probably find your self-confidence steadily increasing.

It’s so important that you do re-evaluate the actual event, perhaps talking it through with someone. Maybe there really is something to be learned. In the example of a violent burglary, you might decide to install a burglar alarm and use it for certain rooms even when you are in the house. If you’ve had a car accident linked to driving in bad weather conditions, you might decide to do an advanced driving course. Work on discriminating between what is a reasoned, more cautious approach, from the probably quite extreme course of action being dictated by your anxiety alone.

Separating then from now

The way our minds store information after a trauma is often a bit jumbled up. At the time of the trauma, everything tends to happen really quickly, and each bit can get tangled up with the others. Quite often an innocuous smell, sound, or even piece of music can take you back into the trauma, which then triggers a complete flashback of the whole event.

If you do experience this, then remind yourself kindly but firmly that that was
then
, but
then
is not
now
. Tell yourself where you are, for instance in a different car, and remind yourself of the date today, and the date of the trauma, to help you separate the then from the now. You can apply this technique to any trauma and it is especially helpful if you are experiencing frequent flashbacks.

Coping with flashbacks

Tell yourself you are having a flashback and that this is OK and very normal in people who have experienced trauma.

Remind yourself that the worst is over – it happened in the past but it is not happening now. Remember: ‘that was then, and this is now’. The traumatized part of you is giving you these memories to use in your healing and, however terrible you feel, you survived the awfulness then, which means you can survive and get through what you are remembering now.

Call on the stronger part of you to tell the traumatized part that you are not alone, not in any danger now, and that you can get through this. Let your traumatized self know that it’s OK to remember and to feel what you feel, and that this will help you in your healing and getting over what happened to you. However hard it is for you, your brain is attempting to heal itself the only way that it can.

Try some of these ways of grounding yourself by becoming more aware of the present:

• Stand up, stamp your feet, jump up and down, dance about, clap your hands, remind yourself where you are
  now
  
• Look around the room, notice the colours, the people, the shapes of things – make it more real
  
• Listen to and really notice the sounds around you like traffic, voices, machinery or music
  
• Notice the sensations in your body, the boundary of your skin, your clothes, the chair or floor supporting you
  
• Pinch yourself or ping an elastic band on your wrist – that feeling is in the
  now
  . The things you are re-experiencing were in the past.
  

Take care of your breathing. Breathe deeply down to your diaphragm; put your hand there (just above your navel) and breathe so that your hand gets pushed up and down. Imagine you have a balloon in your tummy, inflating as you breathe in and deflating as you breathe out. When we get scared, we breathe too quickly and shallowly and our body begins to panic because we’re not getting enough oxygen. This causes dizziness, shakiness and more panic. Breathing more slowly and deeply will stop the panic.

If you have lost a sense of where you end and the rest of the world begins, rub your arms and legs so you can feel the edges of your body, the boundary of you. Wrap yourself in a blanket and feel it around you.

Get support if you would like it. Let people close to you know about the flashbacks so they can help if you want them to. That might mean holding you, talking to you and helping you to reconnect with the present, to remember you are safe and cared for now.

Flashbacks are powerful experiences which drain your energy. Take time to look after yourself when you have had a flashback. Try a warm, relaxing bath, have a nap (not both at once!), have something hot to drink, play some soothing music or just take some quiet time for yourself. You deserve to be taken care of given all you’ve been through.