Section XXVIII: Posttraumatic Stress Disorder (PTSD)

I am a Survivor, Not a Victim—PTSD as Life Saving Adaptation

Goals of the Exercise

1. Eliminate or reduce the negative impact trauma-related symptoms have on social, occupational, and family functioning.

2. Return to the pretrauma level of psychological functioning.

3. Regain confidence in abilities as an effective Soldier, Sailor, Airman, Marine, or Coast Guardsman.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “I Am a Survivor, Not a Victim—PTSD as Lifesaving Adaptation” activity is for veterans/service members whose quality of life and ability to function in one or more domains are markedly reduced by PTSD symptoms. It uses a psychoeducational and cognitive-behavioral approach, reframing PTSD symptoms as functional adaptations to danger that are simply no longer useful, that having adapted to a deadly situation, the veteran/service member has a proven ability to adapt and can do so again, and that adapting to a more benign situation may be hard, but not as hard as adapting to combat. Follow-up can include the exercise “Identifying and Avoiding or Coping with PTSD Triggers,” and can also include reading assignments from books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XXVIII.A I am a Survivor, Not a Victim—PTSD as Lifesaving Adaptation

If you've been told you have posttraumatic stress disorder (PTSD), you may feel some confusion or mixed emotions for various reasons. The terminology can be complicated; the entertainment industry portrays people with PTSD in ways you don't identify with; and in the military and in popular culture, you may have learned to think of people with PTSD as weak, malingering, or too messed up to ever have a decent life. Those are views of PTSD no one would like. On the other hand, it can be reassuring when someone confirms that you had a terrible experience and aren't just feeling sorry for yourself. This exercise will give you a clearer picture of PTSD and a more positive way to look at it. Another exercise that's useful as a follow-up to this one is titled “Identifying and Avoiding or Coping with PTSD Triggers”; it will give you some practical skills for living with PTSD.

1. Let's start with a plain-language definition of PTSD. As defined by the American Psychiatric Association, there are five categories of criteria. The first is just that a person has experienced a traumatic event that involved the actual or potential death or serious injury of that person or someone else, and that he or she felt intense fear, helplessness, or horror. This is often a combat experience, but it could be a violent crime, car crash, work accident, natural disaster, life-threatening illness, or other life-threatening situation. Does this fit for you? What was the situation, and what about it caused your feelings of fear, helplessness, or horror?

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a. If you've had such an experience, there are three groups of symptoms that determine whether you have PTSD. The first group pertains to intrusive recall of the event—they are ways in which the traumatic experience comes to mind when you don't want it to and interferes with your life. This can take the form of memories, visual images, flashbacks, nightmares, or feeling intensely upset if something reminds you of the event. How does this fit your experience?

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b. The next symptom group relates to persistently avoiding reminders of the trauma event and being emotionally numb and distant from others. There are seven different symptoms in this group, and it takes three to diagnose PTSD. Again, how does this fit for you?

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c. The last set of symptoms are signs of hyperarousal, or being jumpier and edgier than before the trauma. There are five, from insomnia to irritability to hypervigilance (inability to relax and stop watching your surroundings). A PTSD diagnosis looks for two or more.

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The final criteria have to do with how long these things have been happening and with how disruptive they are to important parts of your life.

2. Looking over this information you may notice that it doesn't sound as extreme as the portrayals of PTSD we see all too often on TV and in films. It isn't. In fact, in some ways PTSD serves a positive purpose in the right time and place in a person's life—it's a survival adaptation, a proof of the mind's ability to adjust to a very hostile environment and make the changes needed to survive. In the situations that cause PTSD, many of its symptoms improve a person's chance of survival under those conditions. Look back at the symptoms listed: The first group relates to intrusive memories and intense reactions to reminders of the trauma. We need to think about memory's role in self-preservation. It's important to remember dangerous or painful things so we'll be on guard if we face them again. The worse the experience, the more vividly we remember it—did you ever touch a hot stove burner? As for the intense physical and emotional reactions, if we did find ourselves in similar situations, those intense reactions might give us the edge it would take to survive, and having it happen instantly would be a good thing. Has this pattern helped you take care of yourself in a dangerous environment?

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3. The same is true for the avoidance and numbing—avoiding things that hurt us is basic survival, and the emotional numbing is there to help people get through situations without breaking down, like the temporary numbness we sometimes get with physical injuries. Finally, the last group, forms of hypervigilance, is clearly pro-survival in a dangerous environment. So the symptoms of PTSD are adaptations that may have saved your life in the environment where they developed. Does looking at it this way change the emotions you feel when you think about PTSD? If so, describe your before-and-after feelings about it:

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4. No matter how valuable some of these symptoms were in the right circumstances, they aren't making your quality of life better now. But here is a positive but realistic way to think about that: To develop PTSD, you had to make a fast adaptation to a deadly environment possibly without a lot of guidance or support from other people. You did, and you got through some experiences that some other people couldn't. You are a survivor because you proved your ability to adapt. Now, you need to adapt again, but there are three differences:

a. You aren't facing the kind of danger you were before, so you can take more time;

b. You don't have to figure it out on your own—there are a lot of resources available; and

c. You have the benefit of the wisdom and life experience you've gained since then.

This isn't to say it's easy, but it won't be as rough as that first time you had to adapt. As long as you don't give up, you can overcome a lot of the effects of PTSD, as many other veterans/service members have done before you and are doing right now.

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

Identifying and Avoiding or Coping with PTSD Triggers

Goals of the Exercise

1. Eliminate or reduce the negative impact trauma-related symptoms have on social, occupational, and family functioning.

2. Learn and use relaxation and calming strategies.

3. Return to the pretrauma level of psychological functioning.

4. Regain confidence in abilities as an effective Soldier, Sailor, Airman, Marine, or Coast Guardsman.

5. Learn relapse prevention strategies to manage future PTSD symptoms.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Identifying and Avoiding or Coping with PTSD Triggers” activity is for veterans/ service members with PTSD whose quality of life and ability to function in one or more domains are markedly reduced by reactive PTSD symptoms being triggered in their lives. The activity uses a cognitive-behavioral approach like recovering addicts use in regard to potential relapse triggers, guiding the veteran/service member in planning to avoid being surprised by these triggers, to avoid them when practical, and to use proven coping techniques when they are unavoidable. This activity is a follow-up to “I Am a Survivor, Not a Victim—PTSD as Lifesaving Adaptation,” and can itself be followed up with reading from books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XXVIII.B Identifying and Avoiding or Coping with PTSD Triggers

One of the goals of treatment for PTSD is to enable us to live as unrestricted a life as we can by not having to hide from possible triggers for PTSD symptoms. Still, it's smart to plan ahead and avoid triggers if we don't need to expose ourselves to them, as well as planning how to minimize our emotional discomfort when we meet triggers we can't avoid or predict. This activity will guide you in some simple planning that can improve your quality of life.

1. First, it's important to get a clear picture of the kinds of situations, events, and objects that trigger your PTSD symptoms. This will depend largely on the nature of your traumatic experience(s), but if you've been dealing with this for a while, you have a good idea of the general kind of situation that makes it hard for you to stay calm and positive. Please use this space to jot down some information about common patterns in your particular PTSD triggers:

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2. Looking over this information and reflecting on experience, identify some places and situations that are likely to trigger your symptoms. For example, some people get uneasy in crowds, while certain sights, sounds, or smells trigger memories and emotions for others. Please list some situations you have to deal with in the next month that may be upsetting for you in this way. Once you've done this, divide them into categories. One group will be situations you can avoid without any problems as a result; next will be situations you can't avoid, or ones where avoidance would cause more stress in your life than the symptoms that may be triggered; the third type are situations you may encounter, but can't predict when or where.

Can Avoid Can't Avoid Can't Predict
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3. For the situations you can easily avoid, the plan is simple—unless you need to go there, don't. This is a reasonable strategy. A goal of PTSD treatment is to stop being ruled by avoidant behavior, but there's no point in going out of your way to be uncomfortable. If anyone asks about a change in your habits, please describe how you will explain it to them—a simple explanation like “I don't really like crowds,” or something similar, is fine.

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4. Next come trigger situations that are impractical to avoid—maybe they are part of your job, or they are important family occasions. For predictable stressful situations, there are some simple and basic things to do that will make the experiences more pleasant for you. We will present them here, and ask you to fill in the details that will fit your own situations.

a. Support from family and friends: Spend time before the event doing something relaxing with someone whose company you enjoy; if it's somebody that makes you laugh, even better. Let them know the upcoming situation may be stressful for you and get their encouragement. If they will also be there, plan to touch bases now and then during the event; you may also want to plan to go for coffee or something like that afterward so you can relax again.

b. Take breaks: Find a way to step away from the event for a couple of minutes every so often, and when you do make a point of doing some slow, deep breathing and loosening up of any muscles you realize you've been tensing up.

c. Departure plan: Have your departure planned in advance and discuss it with anyone who's going with you so they will know when you plan to arrive and to leave. To avoid inconveniencing anyone, have your own transportation. If this is a party or other gathering of family and friends, you can quietly explain to your hosts in advance why you'll be doing this so they don't think it's about them.

d. Avoid alcohol: If the situation is already testing you, adding alcohol will only make it more stressful and undermine your self-control—stick to coffee, tea, and sodas.

Those are just some starters—you may think of other things that will help you relax and have a more pleasant time. What are some strategies that you will use?

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5. Third, we have the “can't predict” situations. For these, the best approach is to have some simple “immediate action” strategies you've thought through. These might include:

a. Breathing and muscle relaxation routines;

b. People you can call (make sure to have a cell phone and their numbers with you, and have enough names that if some aren't available, you'll be able to get hold of someone else); and

c. Activities to re-calm yourself afterward if you're agitated.

What can you do to stay calm when a high-stress situation takes you by surprise?

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6. If these strategies aren't enough and you find yourself triggered and agitated, focus on physical sensations and your immediate surroundings. Try rubbing your hands together, finding a restroom and splashing cool water on your face, humming, eating or drinking something and focusing on the taste and texture, and paying close attention to the non-triggering things you see and hear around you. Reconnecting with the here and now helps us avoid getting focused on the past and traumatic memories. How can you stay in touch with the here and now?

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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.