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Guidance for using a trauma diary for exposure therapy (cbt)

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anthony

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The following few posts are all about writing a diary, what will happen, how to decrease issues from exposure therapy work (writing about your trauma) and how to construct and maintain a self-help style where you benefit and not just chase your tail in circles.

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Exposure therapy is a deliberate method designed to expose the mind to intense emotional fear (your past trauma) in controlled doses, and teach your body that it now not need be disturbed by traumatic memories, as they are just memories, and that you do not any longer have to take seriously these unbidden memories of your past traumatic experience/s. Exposure therapy is a learning strategy simply designed to separate 'then' from 'now'.

Exposure therapy does not make up the entirety of Cognitive Behavioural Therapy (CBT), as many facets are required to complete the overall healing process, though exposure therapy is certainly a good portion of the trauma healing process.

Are You Suitable for Exposure Therapy?

The main criteria with any CBT method, is that you are not dependent upon alcohol or drug use (suppressants and depressants) which will negatively affect the therapy working for you, and in fact, may even work against you and make you worse if dependent. Please review more information on use, abuse and dependence before considering exposure therapy or CBT.

Why Exposure Therapy?

The reason is simple. You need to come to terms with the full reality of your trauma, and no longer continue that you have it under control with your current coping strategies, which are more often than not, non effective. Whilst many think they have their symptoms under control with alcohol usage, smoking a joint per day, dedicating yourself to working long hours or maintaining a busy lifestyle, each and every time, you end up back at the beginning, with your symptoms prevailing over you, and not you over them.

You need to accept that these types of strategies are not actually coping mechanisms at all, and merely delusional suppressants which are proven non-effective. If you're still having nightmares, still having flashbacks, and still suffering symptoms arising daily / weekly from PTSD, then your strategies are not working for you. You must push yourself from this point past your comfort zone, into an area you have avoided for so long, though an area which must be dealt with to move past the worst of PTSD itself.

If you think of your memories being attached to an elastic band, and the more you push those memories away, the more they spring back at you. This is what the usual suspects within personal coping strategies comprise. Ineffective methods which only tighten the elastic band, and make it pull back more each time you push it away from you. Memories are in concrete within the amygdala and hippocampus, they cannot be erased, nor are they going anywhere. Exposure therapy turns these painful, hurtful memories that you fear, into what they actually are, just memories of the bad times within your past. You will no longer ignore them, but accept them and come to terms with them being part of your past, but without the fear and pain associated to them.

So... Effective Strategies

Effective strategies for exposure therapy are:
  • Writing about the trauma for at a set time for a couple of minutes.
  • Typing something for a few minutes a day (the lesser stressful option).
  • Talking with a confidant for a few minutes each day.
  • Spending a few minutes daily talking and listening to a audio recording of yourself (not recommended for trauma from horror).
  • Setting dares to extend you beyond your comfort levels.
  • Writing about the trauma and its effects in a more documentary style.
This enables you to put the pieces of the jigsaw puzzle back together, and construct a complete picture of the trauma, and not just figment or fragmented memories.

The Aftermath

During exposure therapy, expect to have an increase in negative mood, an increase in symptoms, and a definite impact from your increased mood on friends, family and partners, all of whom may discourage you continuing exposure therapy, as it will negatively impact them also, but a little pre-warning can get around this negative feedback from your support cell. This is short term pain, for long term gain. It is effective, it is proven, and it factually lessens the effect of trauma upon the mind and body, thus having a carry on effect to all other symptoms of PTSD, as the trauma is the ignition of all other symptoms.

Dares... The Art of Successful Recovery

Dares are the therapeutic antidote to the safety behaviours involving learning not so much at an intellectual but primarily at an experiential level, in the gut. Intellectual learning is very much hippocampal learning, where experiential is more at the amygdala based learning. Basically, if you look at how a young child can be taught to not be afraid of the water, they gradually increase the dares as such that are performed in learning to swim at the experiential level (doing) rather than the learning of physics principles, which is what then gives them the confidence to float at a basic level.

Dares are identified between closing the gap between current behaviours, opposed to pre-trauma behaviours. If you used to be capable to going to a crowed shopping centre, or standing in long waiting lines at the checkout, and now cannot, then these would facilitate the dares that you need to perform. These range across your entire behavioural patterns, and are not just limited to one or two of your symptomatic responses now. What must be stressed, is that experiential learning can only be accomplished by triggering the amygdala to the alarm position, which then the alarm rings and it will be quite uncomfortable to you, though afterwards the alarm will come back a notch. The payoff for the alarm coming back a notch is that you will begin to notice improved patterns, ie. sleep will improve with less need for sentry duty, concentration will improve with less effort focused upon your traumas, and the list carries on.

Dares must be timetabled, to prevent avoidance. For example, if you tell yourself your going to perform a dare by going into a crowded shopping centre at late night shopping, then something less trivial arises, you will talk yourself out of the dare. If you timetable yourself to meet someone, or have a coffee with your partner at a coffee shop within that crowded shopping centre at "x" time, you are then more likely to adhere to the appointment time, than talk yourself out of just going into a crowded shopping centre.

The intent of dares is not to be at ease afterwards, but instead disconfirm there expectations that you have created, and learn to tolerate rather than remove distressing emotions. Intentionally inducing the internal alarm to panic is so that the body and mind can see and learn that nothing terrible actually does happen. It is about beating your own thoughts and perceptions that you have now come to believe are reality, when in fact, they are just thoughts and perceptions, and not reality.

MOOD Management

MOOD is a mnemonic for helping people remember their mood altering framework. Construct a table with the following as headers:
  • Monitor mood
  • Observe thinking
  • Objective thinking
  • Decide what to do
The questions that assist you in documenting your mood (first column) for review are:
  • What am I feeling?
  • What mood am I in?
  • What effect is my mood having on others?
  • etc etc... think laterally.
The easiest question to ask yourself to fill in the second column (observe thinking) is, "what have I been saying to myself to feel the way I do?". Answer that honestly, and record your answer in the second column. This is generally the area of most concern as you may not be capable of identifying the actual appropriate thought, however; sometimes the thoughts that are causing the problem could be more at the edge of awareness, ie. a day dream, upcoming event, an anniversary of event, etc. These thoughts are just as relevant, though often harder to identify. If troubled, discuss this on the forum for feedback, as something someone else says might just identify the actual thought for you.

The third column is asking you to be objective in your thinking style, which in essence could be a problem, so you may require others opinions to help you with this. Appropriate questions could be:
  • How true is it?
  • How useful is this way of thinking?
  • Would others be looking at this in a different way? (ask others)
  • etc etc...
The fourth column is about you now putting into practice your more objective way of thinking.

Stuck? Use the forum chat areas to discuss your mood, or discuss this within the trauma diaries itself, to help assist you in identification of particular issues. That is what the forum is about; helping you to answer the questions you are often confused about yourself. We all suffer this self identification process, so you're not alone.
 
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The origins of Cognitive Behavioural Therapy (CBT) can be traced back to the first century (Ad.) where it was observed that people are disturbed not so much by events as by the views which they take of them. The implications of this observation are first that situations, like objects in the visual world, are better viewed from some angles than from others, and secondly that people have a degree of choice in the point of view they adopt. Further, the cognitive theory of emotional disorders postulates reciprocal interactions between the cognitive and other systems, as per the simple cognitive behavioural model displayed below.

cbtmodel.jpg


CBT uses the emphasis upon breaking out of negative chains via the cognitive and behavioural ports of entry. It is also acceptable to break negative chains through the physiological port (exercising) or the emotional port (playing your favourite music). Whilst CBT concentrates on the two primary ports of entry into your mind, the other two are also used in conjunction often with smaller applications to improve functional areas, for example, use of the physiological port with exercise to help break the chain of depression.

Looking now at the more refined model used by most therapist when using CBT to treat PTSD patients, the below image depicts the comprehensive cognitive contextual model of human behaviour to locate the refined cognitive behaviour in a biological interpersonal milieu, and as detailed further on, outlining the processes you will often endure during detailed CBT therapy with a counsellor / therapist.

cbtmodela.jpg


Suitability for CBT

Because you think your ready for change, this does not necessarily reflect if your total surroundings are not ready for the therapy, as the therapy itself requires a great deal of time and effort outside of counselling, to practice new skills and techniques required for change. If a woman for example was living within a women's refuge, then this would not make the idealistic environment for the practice of the new learning theories and techniques to successfully allow improvement within the sufferer.

CBT Structured Counselling

During CBT it is proposed that you will move between the four stages of change, which are:
  1. pre-contemplative
  2. contemplative
  3. action
  4. relapse
These stages will occur and be structured for personal change within the general outline of CBT sessions, which are:

Session 1: Elicit the account of trauma. Rational discussion for targeting the account of the trauma, avoidance and alienation and involvement of significant other. Assigned homework.

Session 2: Review account of trauma, avoidance and alienation. Elaboration of worst moments, identification of saboteurs ie. drinking, drugs, pain, literacy and remedial strategies. Tackling anger. Rationale for tackling co-morbid disorders.

Session 3: Review account of trauma, alienation, avoidance and anger. Engaging with traumatic material and feared situations without being overwhelmed. Review remedial strategies. Re-authoring the account of the trauma and its effects, cognitive restructuring ie. yes... but... (DeCatastrophising).

Session 4: Review homework set, living in the land of approach and immobilising saboteurs. Managing shifts in mood and pain.

Session 5: Stocktaking, review of MOOD records. Introduction to faulty information processes. Weaning off safety behaviours. Connecting and communicating with others.

Session 6 - 7: Stepping around prejudice against self. Reassessment and review of thought records, Mood management and assigned tasks.

Session 8 - 11: Cover any outstanding issues. Distillation of personal protocol to be used in the event of relapse.

Session 12: One month follow-up, review of skills, fine tuning and formal reassessment.

The above is a synopsis only containing the basic outline of what CBT therapy contains. Within each session is then further refined, more specific and detailed information pertinent to each individual, trauma and case.

Realistic Timeline for CBT and Healing

CBT has a realistic expectation for a minimum timeline of 1 - 12 months, as outlined below. This outline can, and most likely will change to suit each individual's specific needs. For example, if a sufferer has relationship breakdowns during therapy, a death in the family, struggles to achieve set tasks, has severe anger problems, or fails to push themselves beyond comfortable. These general life and impact of trauma aspects will certainly play a significant role within the healing process, thus the time of the healing process.
  • 1 - 3 months in CBT sessions
  • 3 - 6 months in follow-up, retraining and reassessment sessions
  • 6 - 12 months recovery to refine skills and learning techniques
By no means after CBT will you be cured, however; what you should have is a fairly stable and balanced focus on life, your relationship, control of your symptoms, and be capable to certainly do more as you once used too, without the symptom outbreaks. Some may be capable of working, some may only be capable of volunteer work, and some may not be capable of working again. Each person varies vastly to their specific trauma and how they have taken it within them.
 
So you get a better understanding of this topic, please quickly peruse the thread on Conceptualising PTSD - Trauma Response To Anger first, as that gives a quick and dirty understanding on how the memories of our trauma, and reactions we have are processed.

The amygdala is the brains alarm, contained deep within our brain. The amygdala is the core of our issues with PTSD, and where we need to start, so you can interpret your own image on how your reactions are forced upon you, instead of the rational decision that often comes second or later, though often too late for the hurtful and spiteful things we say first, from a very misinterpreted and confused amygdala to our output.

The above image represents your amygdala. The normal place for the alarm (amygdala) is over to the left, being the safe place. Now, if something very extreme happens, being your traumatic event, the needle is now moved over to the right side, being the war zone. This is now where your needle rests normally. Now conceptualising the above image, your needle is already in alarm mode, so the slightest event will now trigger your internal alarm to react or respond to the most trivial things. It is like your neighbour having a cheap alarm fitted, whilst it detects a burglar, it also detects a passing truck, birds or a football hitting the house. So realistically, we could call your neighbours alarm faulty. Another model to explain this alarm reaction is the The Ptsd Cup Explanation explanation.

With PTSD, you have developed a similar faulty alarm within your mind, being your amygdala. Unfortunately, each time the alarm goes off, you take it seriously. You may get angry with yourself for allowing your alarm to go off in the first place, though this only makes matters worse. You can no more stop your alarm going off than I could from blinking if I attempt to stick my finger in my eye. Very slowly you can coax your alarm system to move from the extreme right (war zone) backwards towards the Belfast position (being stable, but could explode anytime), then further back to your safe place once again, where a person without PTSD often reside.

Achieving this is not merely an intellectual thing, but a combination of mental thought and exposing yourself to things you avoid. It is like learning to swim. You may know with your head that you will float because of Archimedes Principle, but you only know it at an experiential level when you let go of the side wall in the pool. Inevitably getting the alarm back to the correct position is two steps forward and one back, if for example, you hear in the media of a trauma just like yours, the alarm will move over a notch towards the right, or as you expose yourself to self interpreted fears, and real fears surrounding your trauma.

The drama of trauma is written by the hippocampal system involving the hippocampus and probably the pre-frontal cortex. This system is aware of what’s going on at the amygdala level and can send a message about how seriously the alarm should be taken. The only opposition to this, is that if a particular traumatic aspect was so traumatic, it may off actually bypassed the hippocampus and burnt itself directly into the amygdala instead. This has an impact on memory recovery.

At this point, talking and writing about the trauma, each incident and its effects are a critical aspect in the recovery of lost memories. If you try and block memories when they arise, you will find yourself attempting to think off other things, though the more you try and block the memories, the more you think about them, thus the more symptomatic response.

The Bubble and Emotional Numbness

Those who experience severe trauma can become very concerned about their numbness or emotional flatness, which tends to make you feel like a bottle of soda without the fizz. Whilst the fizz will not return on its own, it will return gradually and often unexpectedly if you engage in increasing doses of activity. Unfortunately, you will feel as though you reside within a bubble.

You will feel as though you cannot connect to others, because of the differing settings of your alarms that they cannot possibly understand if they have not been through the severity of trauma you have. Heroic behaviour means gradually acting opposite to the feeling of flatness and disconnection. To begin with you will feel like a robot going through the motions, but you are pressing into the service part of the brains command / demand system (the anterior cingulate and dorsolateral frontal cortex) that can override fearful messages from the hippocampal / amygdala system, so that over time and with daily practice, the fear may still be there, but it becomes a fear that you are no longer afraid of, more accept it for what it is, a memory.

It takes a lot of energy initially in small controlled doses to burst the bubble you feel that you reside within, and reconnect to people once again. You must not blame yourself for the flatness of fizz or being within your bubble, because you are not responsible for the problem, only for working on the solution.
 
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Where To Start?

Generally before you actually start to write about one traumatic incident, you write a point form of all your traumas, which becomes a reference point for you to begin writing about each trauma. For example, a partial list of one of my own deployments could look like this:
  • Locals attempted to run us off the road and kill us
  • Watched man kill another man with shotgun within 10 metres
  • Had man kill another man with machete
  • Found dismembered male in wheelie bin, arms, legs, head and torso
  • Handling burnt dieing woman who fell in fire
  • Watched children starve to death and die, and from disease
  • Had local threaten to kill me over beating them in a game of pool
  • Had locals threaten to kill me over not giving them supplies
  • Was shot at when unarmed providing humanitarian aid
  • etc etc etc
The above is a point form example list that you would want to create first, as the start of your thread.

Writing

From your point form list, pick the worst trauma you have, and that is the one you write about first. Now your getting scared, however; if you attempt to write about a lesser one first, you can often talk yourself out of writing about the worst one, as the lesser one's will affect you enough to scare you from worst events. Go with the worst first, then all the rest are pushovers compared to that one. It is factual, it does work.

When to Write

When writing you need to write in short bursts, ie. the more you break a trauma down, the easier it becomes that you can write in smaller components, thus you can give yourself daily breaks between them. You can write for a few minutes of recollections, you can write for half an hour if you desire, ie. one full trauma. You know how much you can take. You will feel uncomfortable, don't stop at that point.

When To Stop

Using the Subjective Units of Disturbance (SUDS) scale, which is viewed as a scale of 1 - 10 (10 being the worst), you want to be distressed around the level of 7 - 8 from your one writing episode. DO NOT stop until you have that much distress or you have finished one entire trauma (whichever comes first), though also be mindful to not over extend yourself into a 9 or 10 region, as that area is often critical breakdown.

Finished Writing For The Day

Once your SUDS level is around the 7 - 8 mark, you now stop writing. This does not end your self session though, as now you must read what you have written, as you reread you edit and fill in any points you have missed, or had forgotten, and you must read it to the point until your SUDS level has reduced to around a 3 - 4 range, which generally all of the information has also been recollected and edited into the trauma writing. You’re not going to get worse from reading it, as the majority of that has just overwhelmed you from remembering the trauma and writing it. Reading the specific writing is now going to lessen your fear of that trauma, to the point of the acceptable SUDS level at which point you should no longer fear what you have written, atleast not to the level you had when writing it. Read it, read it and read it, until you are sick of reading it, have a low SUDS level and have remembered all the parts of the trauma and entered them through editing.

Now you walk away from this until such time as you have calmed completely, usually about a few days to a week, sometimes more. You come back and start again when ready.

Generally during the time you are resting from writing, this is the point of analysing what you have written. Points are discussed, suggestions made, you map out your plans into actions, you continue.

Conclusion

Having read the above, approach cautiously and with common sense for self-moderation of symptoms.
 
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