Section XXVI: Physiological Stress Response—Acute

Quick Strategies for Coping with Intense Stress Response

Goals of the Exercise

1. Decrease hypervigilance and hyperarousal to levels that are manageable.

2. Prevent development of posttraumatic stress disorder.

3. Verbalize an understanding of typical reactions to a traumatic stressor.

4. Verbalize an understanding that cognitions contribute to the maintenance of fear, hypervigilance, and hyperarousal.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Quick Strategies for Coping with Intense Stress Response” activity is intended for use with veterans/service members who experience intense hypervigilance and hyper-arousal in response to trigger events, either internal (cognitions) or external (events in the immediate environment). It takes the psychoeducational and solution-focused approach of teaching the veteran/service member to identify this process as early as possible and self-intervene using cognitive and behavioral strategies to maintain or regain physical and emotional equilibrium. Follow-up could include reporting back to the therapist/therapy group on outcomes of the strategies from this exercise and reading assignments from the books listed for this issue in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XXVI.A Quick Strategies for Coping with Intense Stress Response

The human mind and nervous system respond to emergencies with rapid changes from everyday levels of arousal to escalated alertness, physical readiness for combat or escape, and accelerated thinking and decision-making. This can save our lives, but this state is too intense to spend much time in without heavy wear and tear, physical and mental. Unfortunately, we can get stuck in a mode where that crisis response is on a hair-trigger and can be easily set off. It may end up getting triggered so often that this defense against trauma becomes a source of trauma itself and takes a heavy toll on our quality of life and even our health. This exercise will show you some ways to catch this process as early as possible and, when it isn't necessary, reverse it quickly and regain a state of calm.

1. First, let's see what changes occur when we go from a normal state to emergency mode. Mentally, we normally divide thoughts and attention between tracking and responding to the immediate situation on one hand, and inner thoughts on the other. You may be driving home from work, listening to a song on the radio, thinking about your plans for the weekend, and deciding whether to stop at a store. If the trip home is routine, the chances are good that you won't even remember a lot of the drive—you could say that part of your mind was on autopilot. It's a different story if you encounter a situation your brain interprets as a crisis—such as the driver in front of you slamming on his brakes. Instantly, you are no longer aware of the radio, and your thoughts about the weekend and the grocery store are gone—your full attention is on avoiding a wreck, and you will definitely remember this when you get home. Thinking and decision-making speeds up, sometimes so much that it seems to us the world has gone into slow motion. What are some other situations where you've experienced this instant high alert?

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2. The body goes through similar changes. At rest, our breathing, pulse, and blood pressure are in economy mode, just keeping the body working smoothly. Most muscles are relaxed and a lot of the body's energy and oxygen supply is going to routine functions like digesting lunch. But when the brain sends the crisis signal, the change happens in a heartbeat. The adrenal glands dump adrenalin, the body's own stimulant, into the bloodstream. The blood supply and the oxygen it delivers shift instantly to the large muscles needed for fight or flight, switching off non-crisis functions like digestion. That's why we get the feeling called “butterflies in the stomach.” Pulse, breathing, and blood pressure spike; vision and hearing even get sharper. This change can be so intense it feels like an electric shock. The body is ready to do anything it takes to survive. When have you experienced this, and what did it feel like?

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3. In a tenth of a second we've gone from relaxation to readiness for maximum focus and effort. It might seem that it would be an advantage to just stay in that ready-for-anything condition all the time. But it's very hard on the mind and body. If we spend a lot of time in that state it causes severe wear and tear—it ages us rapidly and it can make us sick. Also, if this happens a lot, the brain decides that we must be in a very high-risk environment and keeps getting more and more sensitive to alarms, until our emergency mode is in hair-trigger mode and is often set off in situations that aren't really crises, like a too-sensitive car alarm. If you've experienced any physical fallout from frequent intense stress responses, describe it here:

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4. To avoid getting sick and worn-out, we need to find ways to reverse this mental and physical change quickly when we see that we aren't really facing a crisis. Just as that switch is both mental and physical, so is the reversing process. Notice the wording in question 2 about what sets it off: “a situation your brain interprets as a crisis.” The word “interprets” is important. When the mind develops that hair-trigger oversensitivity, we get false alarms, but the body gets its orders from the brain and doesn't know that. As the brain realizes it's not facing a threat after all, we need to take the body back to normal mode, which involves both rethinking the situation and direct physical action. Note: it's better not to use alcohol or other drugs for this purpose. They suppress the symptoms more than relieve them, and that stress response may come back when the chemical wears off.

Resetting the brain to normal mode has two parts. First, ask yourself, “What's the threat?” If it's already past—you stopped without hitting the car ahead—or if it was something your brain misinterpreted for some reason, it's safe to mentally thank the brain/body emergency system for doing its job and focus your thought on the new situation. You might say to yourself something like “Crisis over, no current threats,” and switch to directing the body's shifting gears. For the body, try concentrating first on taking deep, slow breaths from the belly, then on paying attention to each part of the body in turn, tensing the muscles for a few seconds and then relaxing them, paying close attention to how it feels. You can follow up with a relaxing thought or visualization like the one in the activity titled “Safe and Peaceful Place Meditation.” With practice you can use that method to become completely calm in a few seconds. If you've found ways to get back to a relaxed state quickly after being triggered, what works best for you?

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5. Finally, let's come back to the important fact that this response is based not on the situation, but on how the braininterprets it. If you're experiencing a lot of false alarms, you can work on reprogramming that part of your brain so it's not on such a light hair-trigger. Individual and group therapy can help a lot, and any well-stocked bookstore has a whole section of books on subjects related to this. How will you explore your options for making your mind less prone to interpret non-crisis situations as emergencies?

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Be sure to bring this handout back to your next therapy session, and be prepared to discuss your thoughts and feelings about the exercise.

Safe and Peaceful Place Meditation

Goals of the Exercise

1. Decrease hypervigilance and hyperarousal to manageable levels.

2. Eliminate agitation, irritability, and sleep disturbances.

3. Reduce or eliminate negative physical effects of prolonged/severe hyperarousal.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Safe and Peaceful Place Meditation” activity is useful for managing stress and anxiety, particularly if these are chronic. It is also useful for pain management and coping with insomnia. This exercise guides the veteran/service member in a personalized multisensory imagery exercise in which he/she creates a mental construct of a safe and peaceful place and practices temporarily withdrawing from engagement with stressors. With practice, this exercise is an effective way to achieve quick relaxation. It can be used in individual or group therapy and as an opening for groups. Follow-up can include practice at home and reporting on outcomes. Often, teaching the exercise to others is a very effective way to master it. Some veterans/service members may benefit from biblio-therapy using the book We're All Doing Time by Bo Lozoff or other books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XXVI.B Safe and Peaceful Place Meditation

Do you sometimes wish you could just get away from whatever situation you're in, or from whatever you're thinking and feeling? This is a normal and healthy wish. It may not be practical to actually leave a situation right away, though, and sometimes it's hard to leave our own thoughts and feelings behind even when we do physically go somewhere else.

This exercise will teach you how to get away even when you can't go anywhere. It will guide you through a process of creating a mental picture of a safe and peaceful place where you can temporarily relax, so that you can come back to your situation calm and refreshed. Practice is important. The more you practice this, the better you'll get at it and the better it will work for you. With enough repetition, people have used this to achieve calm and inner peace very quickly, often in a few seconds, even in the midst of great pain, anger, and/or anxiety.

For many people, it works best to do this with their eyes closed, so you may want to have someone you trust and feel safe with read this to you while you follow the instructions, or record it in your own voice to play back and listen to.

1. Image. What is a place that makes you feel calm, peaceful, and safe to think about? Please think of the place that best fits this description for you and form a mental picture of it. It may be a real place you've been—anything from a favorite beach to your grandparents' kitchen; a place you've heard about and would like to go; or an imaginary place. Whatever is relaxing for you is right for you. Briefly describe this safe and peaceful place.

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2. Emotions and sensations. Focus on this image or mental picture. What emotions do you feel? What pleasant physical sensations do you feel, and where are they located in your body?

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3. Enhancement. Please explore this imagery in more detail. Take a few moments to savor it with all your senses and enjoy the idea of being in this safe and peaceful place. When you look around this place in your mind's eye, what do you see happening? What do you hear? Is it warm or cool? What does the air feel like against your face? Is there a distinctive aroma? Please describe these sensory details.

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4. Cue or key word. Please think of a single word to represent this picture, and keep this word in mind while you once again bring up the mental picture—the sights, the sounds, and all the sensations of peace and safety and pleasure in this place you've created for yourself. Focus on whatever pleasant things come to each of your senses in turn, keeping this key word in mind. Now let your mind dwell on those pleasant sensations and repeat the key word to yourself over and over. Try blanking out the pleasant place you have been thinking of, then thinking of the key word, and see how the image comes back to you quickly and vividly. Notice how your body is feeling relaxed.

5. Coping with mild stress. Let's test this as a way for you to relax and overcome negative feelings. Blank out your safe and peaceful place again. Now think of a minor annoyance, a situation or person that isn't a big problem but gets on your nerves. What kinds of negative physical sensations are coming to you when you think of this annoyance? Where are they located in your body?

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Now think of your key word. Again, think of the safe and peaceful place in your mind's eye that goes with the key word. Think of the visual image, the scenery, the sounds, and the pleasant physical sensations. As you think of this, how does your body feel? What is happening to the negative sensations you felt in your body?

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6. Practice. For the next two weeks, practice this at least twice a day, and use it when you find yourself getting irritated or anxious. You can also use it when you are feeling physical pain or discomfort, or if you have trouble sleeping. As you practice, keep noticing anything about the mental image of your peaceful and safe place that makes it more vivid and more relaxing for you, and keep those details in mind for future times when you do this exercise. As an added help to learning to use it, try teaching it to someone else and see how it works for them.

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Use this space to record anything you noticed or learned while doing this meditation exercise.

Be sure to bring this handout back to your next therapy session, and be prepared to discuss your thoughts and feelings about the exercise.