Self Help for Post-Traumatic Stress

If the answer to any of these questions is 'yes,' you may be experiencing symptoms of post-traumatic stress and you may find this workbook helpful.

This workbook aims to help you to:

Contents of this Self Help Guide

Strategies that you could use to overcome your post-traumatic stress:
  1. Understanding more about post-traumatic stress.
  2. Learning how to challenge your unhelpful thoughts and see things in a more realistic light.
  3. Learning how you can feel more relaxed, both physically and mentally.
  4. Learning how to stop avoiding the things that make you anxious.
  5. Learning strategies to help you stay active and make good use of your time.
When going through this booklet it might be helpful to try out each strategy one at a time, rather than trying to learn them all at once. However, simply take things at your own pace.
Do I have symptoms of Post-Traumatic Stress?

If you experience symptoms of Post-Traumatic Stress it is likely that you will recognise many of the feelings, physical symptoms, thoughts and behaviour patterns described below.

Please tick the boxes which regularly apply to you.

Feelings

Fearful / Scared
Emotionally numb
Furious / Raging
Sad / Tearful
Irritable
Overwhelmed / Helpless






Physical Symptoms

Restless
Heart racing
Disturbed sleep pattern
Sweating
Tense muscles





Thoughts

I'm to blame for what happened
I'm out of control
Why has this happened?
Something awful might happen
Flashbacks or nightmares of the event
It's going to happen again






Behaviour Patterns

Restless and distractable
Angry outbursts and antisocial behaviour
Avoiding social contact
Hyper-alert and easily startled
Avoiding things relating to the trauma





If you have ticked a number of these boxes it is possible that you experience symptoms of Post-Traumatic Stress. However, don't be alarmed. By following the steps in this workbook, you may be able to learn how to improve your situation.

What is Post-Traumatic Stress?

Post-Traumatic Stress can occur after a significant incident that is out of the ordinary. A person involved in such an event might have witnessed an injury or death. You might have been in danger of this yourself. It could have been a large scale disaster, or a small but significant accident. For example:
  • Being attacked or assualted
  • A road traffic accident
  • A house fire
  • An incident at work
  • A natural disaster
An initial reaction to such an event might be shock and disbelief. Over time this can fade. More troubling thoughts and feelings can emerge. These might include anger, helplessness or fear. It can be difficult to process your memories of the event, or understand what happened and why. You might re-experience the incident through intrusive flashbacks or nightmares. Following such an experience, it is also common to avoid things that remind you of the incident.

What causes Post-Traumatic Stress?

Life Events:
The experience of a traumatic event can trigger significant difficulties in everyday life. Coping with the consequences and impact of an unexpected and severe incident, or even several incidents, can be extremely challenging. Often after such an incident it is difficult to understand what happened and reason through why it might have occurred. The memory of such an event, as it holds such significance, is also kept readily accessible. Recalling and trying to process these events may cause more upset and distress. It can, however, be helpful in order to eventually resolve these difficult emotions.
Thinking Styles:
Experiencing an incident can directly challenge our beliefs about the world, about ourselves, and about life in general. For example, shattering our view of the world as being safe, predictable and secure, and life being manageable and meaningful. This can often result in a change in the way that we relate to ourselves and other people.
Behavioural Explanations:
Experiencing a traumatic incident may effect our behaviour. We might begin to avoid certain places, activities or people. This may be because they are directly related to the incident, or that it triggers a memory of the trauma.
In reality it is likely that a combination of all these factors influence someone's Post-Traumatic Stress. However, in some ways it is less important to know what causes Post-Traumatic Stress, and more important to know what stops us moving past it.
What keeps Post-Traumatic Stress going?

Following an incident you may find that avoiding the location, activity or people involved is an effective way of coping with your distressing circumstance. In the long-term this may not be helpful. Adapting your behaviour to avoid those things might maintain your difficulties, rather than resolving them by working through the problem.

When looking more closely at what stops us from overcoming Post-Traumatic Stress, it becomes clear that our behaviour, thoughts, feelings and physical sensations all interact and combine to keep it going.

Understanding your Post-Traumatic Stress

Have a look at some of the examples and try to fill in something of your experience. See if you can recognise a similar pattern occurring within yourself.

How have you been coping so far?

You may have been dealing with at least some of these difficulties for a while already. Think about what you've done so far to cope, and how effective these strategies have been.
Challenging unhelpful thoughts

The way that we think about things has an impact on our mood. Many of these thoughts occur outside of our control, and can be negative or unhelpful. It is therefore important to remember that they are just thoughts, without any real basis, and are not necessarily facts. Even though we may believe a lot of our unhelpful thoughts when we have experienced a traumatic event, or feel stressed or low, it is good to remember that they should be questioned as they are often based on wrong assumptions.

The following section will help you begin to recognise if you are thinking about things in an unhelpful or unrealistic way, and discuss how you can start to make changes to this. By doing so, you can learn to see things in a more realistic light which can help to improve your mood. You might have unhelpful thoughts about all kinds of things. Here are some examples:

About Yourself / Your Actions and Thoughts:

  • I may not be able to cope
  • I'm helpless
  • I'm in danger, something might happen to me
  • I am to blame
About the World
  • The world is dangerous and threatening
  • The world is an unpredictable place
It is clear to see how this kind of thinking might bring your mood and confidence levels down. Do you ever think in any of the ways outlined above? Fill in your examples below:
You might find it difficult to identify an unhelpful thought. Try thinking about a time when your mood changed, perhaps when you were thinking about a traumatic event. Consider what was running through your mind at that time.
Patterns of unhelpful thinking

First you need to be able to recognise an unhelpful thought. Then you can challenge it. Being aware of the common patterns that unhelpful thoughts follow can help you to recognise when you have them. Here are some of the common patterns that our unhelpful thoughts follow:

Predicting the future
Catastrophising
What if?
When people are worried about something it is common for them to spend a lot of time ruminating. You can end up thinking about the future and predicting what might go wrong. This is instead of just letting things be. You might blow things out of proportion, or come to expect a catastrophe. For example:
  • Something terrible is going to happen.
  • What if they're waiting for me.
  • What if it happens again.
Jumping to conclusions
Taking things personally
Mind reading
When people are feeling emotionally vulnerable, it is likely that they take things to heart and become more sensitive to what people say. They can often make assumptions about why someone said something, beign overly quick to draw conclusions, and thinking that they are the focus of what has been said. For example:
  • You think that a friend has ignored you, but in fact they have other things on their mind.
  • They must be about to attack me.
Focusing on the negative
Ignoring the positive
Filtering
Often people can ignore the positive aspects of life or their situation. Instead you may focus on negative elements. This style of thinking stops us feeling good about ourselves. It can lower your confidence. For example:
  • This event has ruined my life
  • I was only able to cope on that occasion because...
Black & white thinking
All or nothing
Perfectionism
"Should" thinking
Sometimes people only see things as black or white, with no grey area or in-between. Having this polarised view can lead some people into setting themselves impossibly high standards, being overly critical and struggling to recognise any achievement due to their perfectionism.
  • That was a complete waste of time.
  • They must hate me.
  • I should always get full marks.
Over-generalising
Labelling
Based on one isolated incident you might assume that other events will follow a similar pattern in the future. You might find it hard to see a negative event as a one-off. This can also mean that you label yourself, often unkindly, which can lower your mood and confidence, perhaps even leading to feelings of hopelessness. For example:
  • Failing my driving test means I'll fail at everything.
  • The neighbour's dog snarled at me, all dogs are vicious!
  • I'm useless

Do any of your unhelpful thoughts follow some of these patterns? Jot down any examples you can think of into the box below:

We can learn techniques to challenge these unhelpful thoughts. This can help to improve your mood. The next part of this handout will discuss how we can go about challenging our unhelpful thoughts. You may come up with a more balanced thought that is accurate and based on evidence.
How to challenge unhelpful thoughts

Once you have recognised an unhelpful thought the next stage is to challenge it. To do this, you can ask yourself a serious of questions. See the example below:
Situation: Taking a walk in the evening along a path.

How you feel: Fearful, on edge, worried.
Unhelpful thought: I'm going to be attacked!
Challenges to an unhelpful thought

Now you can challenge your unhelpful thoughts by asking these questions.

Is there any evidence that contradicts this thought?
  • I've walked this way many times before.
  • Lots of people walk this way.
Can you identify any of the patterns of unhelpful thinking described earlier?
  • I'm catastrophising.
  • Fearing the worst (what if…).
What would you say to a friend who had this thought in a similar situation?
  • Lots of people walk there, there's no reason why you would be targeted.
What are the costs and benefits of thinking in this way?
  • Costs: It makes me anxious to walk that way home, any other way is much longer. It reminds me of when I was attacked before.
  • Benefits: I can't really think of any.
How will you feel about this in 6 months time?
  • I'll probably look back and laugh about how silly I was being.
Is there another way of looking at this situation?
  • I've walked this way so many times - it's completely safe.

Once you have asked yourself these questions, you should read through your answers. Try to come up with a more balanced or rational view. For example:

I have walked along here plenty of times, it is no less safe than it was before I was attacked on that one occasion. I can manage these feelings of anxiety.
Try to apply these questions to the unhelpful thoughts that you notice. It can help to improve your mood. You can use this technique to test your thoughts are realistic and balanced.
Relaxation

It is important to make time to relax and do activities that are enjoyable. This can help to improve your mood by calming the body and mind. It can also help you to sleep. Without taking the time to unwind, it is easy to feel overwhelmed and stressed.

Relaxation can involve doing something that you enjoy, or just being by yourself. Good examples might be reading a book or having a bath. Exercise is also particularly effective at helping us to relax. What you do does not really matter. Try to choose something that you will look forward to and that gives you a break. Doing an activity that you enjoy will also give you less time to spend worrying. Here are a list of activities that might help you to relax.

Suggestions:
  • Do some exercise (e.g. swim, cycle)
  • Read a book
  • Watch your favourite TV show
  • Go to the cinema
  • Do something creative (e.g. draw, paint)
  • Visit a friend or family member
  • Have a bath

Try to add some of your own ideas into the box below. You will know what works best for you.

Try to find time to relax every day. This might seem difficult, but it is worth making time for. It can help you to feel a lot better. There are audio relaxation guides available that you might find a helpful support.

There are also some exercises described in the next few pages. They are specifically designed to help you to relax. However, you should stop the exercise if at any time you begin to experience discomfort or pain.

Controlled breathing

This simple technique involves focusing on and slowing down our breathing patterns. Many people find this simple exercise very relaxing. It can be particularly helpful for those who feel dizzy or light headed when they feel worried or stressed. This sometimes happens because people's breathing changes and gets quicker when they feel distressed.

This can be an uncomfortable and unpleasant experience. It can make people even more on edge, and a vicious cycle can occur. Learning controlled breathing exercises can help you to manage these feelings more effectively. It can also help to give your mind and body a chance to calm down.

Remember, you can use this exercise to help you relax at any time. You could even use it to help you get off to sleep. However, it is particularly useful if you ever feel light-headed, dizzy or faint.

Beginning

Get into a comfortable position.
Middle

Work out a stable breathing rhythm. Perhaps try to breathe in for three seconds, hold this breathe for two seconds, and then breathe out for three seconds. It can be helpful to count as you do this (e.g. IN: 1-2-3, HOLD: 1-2, OUT: 1-2-3, HOLD: 1-2).
Ending

Repeat this action for a few minutes. You should soon begin to feel more relaxed. If you were feeling dizzy then this should also get better after a few minutes.

Muscular relaxation

Tension often builds up when we feel upset or stressed. These symptoms can be painful and can cause anxiety in themselves. Muscular relaxation exercises can help you to control such unpleasant symptoms. They can reduce physical tension and help you to relax in general.

During this exercise you have to tense and then relax different muscles in your body. You should focus on the feelings that you experience whilst doing this. With practice you will then be more able to recognise and respond to the onset of tension.

You can work through as many muscle groups as you like. Don't feel that you have to cover every muscle in your whole body. It can be helpful to stick to the same muscle groups each time you practice. That way you can get into a routine which you can easily remember. If you practice this nearly every day you will probably notice an improvement after a couple of weeks.

Beginning

Find somewhere comfortable and quiet where you won't be interrupted. You can either sit or lie down to practice this exercise. Begin by focusing on your breathing. Try to have a slow and comfortable pace. You could use the controlled breathing technique described earlier. Do this for a few minutes to prepare for the muscular relaxation exercise.
Middle

Try to tense each muscle group for around five seconds. Don't tense the muscle too tight. Focus on the sensations that this brings. Then relax your muscles for a similar length of time, and again, focus on how this feels. Then move onto the next muscle group. Try to remember to keep your breathing at a comfortable pace throughout. Below are some suggestions of muscle groups that you may wish to work through:
  • Legs - point your toes and tense your muscles as if you were trying to stand up.
  • Stomach - tense your stomach muscles.
  • Arms - make fists and tense your muscles as if you were trying to lift something.
  • Shoulders - shrug your shoulders. Lift them up towards your ears.
  • Face - make a frowning expression. Squeeze your eyes shut and screw up your nose. Clench your teeth.
Ending

It can be helpful to spend a few minutes just lying quietly in a relaxed state. See if you can notice any tension in your body and try to relax it. Otherwise, just let the tension be. If your mind wanders, try to bring your concentration back to your breathing.

Finally, count down silently and slowly: 5-4–3–2–1-0, and come out of the relaxation in your own time. See if it's possible to carry that relaxed feeling into whatever you do next.

Distraction

Distraction is a good technique to fend off symptoms of anxiety and stress when they feel overwhelming. This can also give you space to deal with a situation in a more considered and positive manner. It is also helpful when you don't have the space or time to use a more proactive approach, such as a relaxation exercise.

Distraction simply involves trying to take your mind off uncomfortable symptoms or thoughts. You can do this by trying to focus on something unrelated. Often this helps them to pass. It is still important to remember that the symptoms of anxiety are not harmful or dangerous. Even if you didn't use distraction or relaxation techniques, nothing terrible would happen.

Ideas to help distract you from your troubling thoughts or anxiety include:

  • Try to appreciate small details in your surroundings.
  • Count backwards from 1000 in multiples of 7.
  • Focus on your breathing, for example, how it feels to breathe in and out.
  • Count things that you can see that begin with a particular letter.
  • Visualise being in a pleasant, safe and comfortable environment (e.g. being on a beach).
  • Listen to your favourite music. Try to pick out all the different instruments and sounds that you can hear.
As with any relaxation exercise, it may take a few minutes before you begin to feel like it's working.
Reducing avoidance

People often get into the habit of avoiding situations that cause them difficulty. This coping strategy can unfortunately make the problem worse. This is because the longer we avoid something, the more intimidating it becomes. By avoiding situations we also stop ourselves from proving that we can cope in them. As a result our anxiety towards the situation continues and our confidence remains low. Take the example below:

Having a car accident that resulted in anxiety about driving.

Not feeling able to drive locally.
Refusing to be a passenger on the motorway.


By avoiding these situations there is no opportunity to practice or prove that they could cope well.

It is easy to see how using avoidance as a strategy to cope can soon begin to have a negative impact on people's lives as they start to avoid more and more situations. If instead we confront difficult situations then it is possible to build up our confidence. This will help your anxiety to reduce significantly.

Physical feelings are experienced when your body reacts to stress, fear or anxiety. For example, being reminded of a trauma or having a flashback. These symptoms are often referred to as the 'fight or flight' response. This reaction quickly and helpfully prepares the body for action. It prepares us to either protect against or escape danger.

  • Making our heart beat faster - to supply more blood to our muscles.
  • Producing more sweat - to cool us down.
  • Tensing our muscles - getting them ready for action.
  • Taking deeper and quicker breaths - to supply oxygen to our muscles.
  • Shutting down body functions that aren't needed at the time e.g. digestion.
  • Racing thoughts - quickly narrowing the available options to make a quick response.
In the past such a reaction would have offered us some protection. Preparing us to react quickly in case of predators, and aiding survival as we hunted and gathered food. These days we do not depend so much upon running or fighting as we negotiate difficult circumstances. The symptoms described above are therefore less helpful. They may even end up being quite confusing. Threats like dark nights, loud noises, or someone walking along behind do not require such an extreme physical reaction. These symptoms are not dangerous in themselves. In many ways it is a useful response, but at the wrong time. We need not fear the fight or flight reaction. It is our body's healthy protection system. Understanding this can help you to manage the physical symptoms. You need not worry about them or feel that you need to respond or react. You can allow them to pass, as they will do quite quickly.
Exposure

If we find ourselves in a difficult situation, then it can be tempting to run away or escape. By doing this our anxiety levels drop rapidly and we can feel quite relieved. It is almost like rewarding ourselves for not having stuck with the anxiety.

Getting into the habit of escaping from situations can reinforce your avoidance. If, on the other hand, you manage to stay with the anxiety in the situation, instead of escaping, then it will eventually reduce. Repeated and sustained exposure can defuse your anxiety towards a situation over time.

Sometimes, extreme situations are re-experienced as dreams or flashbacks. It may be possible to deal with these in a similar way. This can involve imagining or thinking through the situation repeatedly. As you become more familiar with the experience you may begin to feel less uncomfortable. You can acheive this by writing down your experience, looking at pictures, or speaking about what happened. This process can help you to actively and effectively manage your anxiety that has resulted from having experienced this situation.

This may sound daunting. You should work through this process gradually, and perhaps seek support. The next few pages will discuss ideas to help you work through the process.

List the things that you avoid

Come up with a list of the situations that you often try to escape from or avoid. For example:
Ranking these situations

Rank your list of situations in order of difficulty. From the least anxiety provoking to the most anxiety provoking on a scale of 0-100. 0 = no anxiety and 100 = extreme anxiety.
For example:

Once you have done this, try to organise your items from least anxiety provoking to most anxiety provoking.

Confronting the lowest ranked situation
Try to confront the lowest ranked item on your list. This will be the item that causes you least anxiety. You will likely find that although your anxiety might initially rise, it will drop if you remain in the situation for long enough. Try to stay with the situation until your anxiety has reduced by at least half.
Repeating this task

Repeat the task as often as possible (every day if you can). Try not to leave too long between times when you confront this item. This is because the more you confront something, the more your fear will reduce. You should notice your anxiety getting less and less each time you do so. You may find eventually that it will cause you little or no anxiety at all.

Moving on to the next lowest item

When you feel comfortable with an item, try to move on to the next item on your list. Working through your list you will begin to feel anxious in fewer and fewer situations. You should find that your confidence grows as you move on from each item. You should find that tasks ranked as more difficult seem more manageable as you progress.

Things to consider:
  • Don't fear the symptoms of anxiety. Anxiety is a natural and healthy reaction that is not dangerous.
  • Try not to escape situations you fear half-way through. Stay, and your anxiety will eventually decrease.
  • Your anxiety will reduce each time you confront a feared situation. Try to confront your fears as often as possible.
  • You may also find it helpful to challenge any unhelpful thoughts as you face a fear.
  • Look out for other situations that you avoid due to anxiety. Try to gradually reduce your avoidance more and more.
  • You may confront an item on your list which doesn't go as well as you had hoped. Try not to give up. Persevere, and it should eventually get easier.
  • If an item on your list seems too hard, see if you can put in an extra step or two before it. This will allow your confidence to rise further before you face it.
Making Good Use of Your Time

When we feel have experienced a traumatic event, or feel stressed or low, our motivation to do things often decreases. You may find that you give up hobbies or activities that you previously enjoyed. Over time you might end up doing very little. This can lead you to feel even lower and a cycle can begin which is difficult to escape from.

By using a diary to plan your week in advance, you may be able to do more of the things you want to, in addition to the things that you have to do. This can really help to lift your mood. This section aims to give you advice that will help you to plan your weeks well.

When completing your diary, start by filling in all the activities that you have to do. For example, preparing meals, doing housework, attending appointments, etc. This will show you all the time that you have free. Then you can begin to plan other activities that you would like to do. Remember to pace yourself. Give yourself space to be busy or take time out to relax. You may find it helpful to plan in some time for:

  • Socialising – social contact often helps us feel better, even though you may not feel like it at times.
  • Hobbies and interests – this might be something you have enjoyed in the past, or a new project.
  • Exercise – this can improve your mood and general health. It doesn't need to be anything too energetic. Just going for a walk regularly can be a good option.
  • Bedtimes - try to plan regular and consistent bedtimes. Having a regular sleeping pattern can help improve your mood and energy levels.
  • Time for yourself - make time to relax and give yourself space between activities.
Some ideas have been provided in the box below that may help you get started. We all have different interests, so try to do things that you know will work for you. Fill in your ideas in the space provided:

Now try to complete a plan for a week. You don't have to fill in every space - this can be quite difficult. You could start by just adding in one or two new activities for each day.

Once you have filled in your diary, all you have to do is try to follow your plan each day. Don't worry if unexpected things come up and you cannot stick to it exactly. In fact, it is very unlikely that things will go exactly as you planned. It is also fine to be flexible and replace some activities with new ones. Leave out some tasks altogether if you don't have time for them. Try to be relaxed if this happens.

Final Word

We hope that you found some of the ideas in this booklet useful. You can continue to use the techniques you found helpful long into the future and they should continue to benefit you. If some of the ideas are not particularly helpful at first, it is perhaps worth sticking with them for a few weeks to give them a chance to work. If however you feel your situation remains largely unchanged or if you did not find this booklet useful, you should speak to your GP who can tell you about the other options available which you could find helpful.

Further Information and Resources

For further information and self-help resources go to Moodjuice online:

http://www.moodjuice.scot.nhs.uk

Moodjuice is a website designed to offer information and advice to those experiencing troublesome thoughts, feelings and behaviours. In the site you can explore various aspects of your life that may be causing you distress and obtain information that will allow you to help yourself. This includes details of organisations, services and other resources that can offer support. This self help guide comes from a series that you can access and print from Moodjuice. Other titles available include:

  • Depression
  • Anxiety
  • Stress
  • Panic
  • Sleep Problems
  • Bereavement
  • Anger Problems
  • Social Anxiety
  • Phobias
  • Traumatic Stress
  • Obsessions and Compulsions
  • Chronic Pain

Some Useful Organisations

The following organisations or services may be able to offer support, information and advice.

Samaritans
Samaritans provides confidential emotional support, 24 hours a day for people who are experiencing feelings of distress or despair, including those which may lead to suicide. You don't have to be suicidal to call us. We are here for you if you're worried about something, feel upset or confused, or you just want to talk to someone.

Phone:
08457 90 90 90

Web Site:
http://www.samaritans.org
Victim Support Scotland
Victim Support Scotland provides emotional support, practical help and essential information to victims, witnesses and others affected by crime. The service is free, confidential and is provided by volunteers through a network of community based victim and youth justice services and court based witness services.
Phone:
0845 603 9213

Web Site:
http://www.victimsupportsco.org.uk
Rape Crisis Scotland
The Rape Crisis Scotland National Helpline provides crisis support for anyone in Scotland affected by sexual violence at any time in their lives.
Phone:
08088 01 03 02

Web Site:
http://www.rapecrisisscotland.org.uk
Breathing Space
Breathing Space is a free, confidential phone line you can call when you're feeling down. You might be worried about something - money, work, relationships, exams - or maybe you're just feeling fed up and can't put your finger on why.
Phone:
0800 83 85 87

Web Site:
http://www.breathingspacescotland.co.uk
Living Life to the Full
Living Life to the Full is an online life skills course made up of several different modules designed to help develop key skills and tackle some of the problems we all face from time to time.
Web Site:
http://www.llttf.com/
ASSIST - Assistance Support & Self Help in Surviving Trauma
Phone:
01788 560800

Web Site:
http://www.traumatic-stress.freeserve.co.uk/webstart.htm

Further Reading

The following books may be able to offer support, information and advice.

The PTSD Workbook
This workbook offers the most effective tools and strategies - recommended by PTSD experts worldwide - to help readers conquer trauma-related symptoms. PTSD is an extremely debilitating anxiety disorder that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Often individuals with PTSD repeatedly reexperience the ordeal in the form of flashback episodes, recurring memories, nightmares, or frightening thoughts. PTSD symptoms include emotional numbness and sleep disturbances, poor concentration, depression, anxiety, and irritability or outbursts of anger. In The PTSD Workbook, two psychologists gather together techniques and interventions used by PTSD experts from around the world to offer trauma survivors the most effective tools available to conquer their most distressing trauma-related symptoms. Readers determine the type of trauma they experienced, identify their symptoms, and learn the most effective techniques and interventions they can use to overcome them.

Author: M B Williams & S Poijula
Published: 2002

Understanding Your Reactions to Trauma: A Guide for Survivors of Trauma and Their Families
The last thing you probably feel like doing after a trauma is to read a book about trauma. While getting away from your experience may make you feel a little better in the short term. It won

Author: C Herbert
Published: 2002