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Do not let yourself speak badly to yourself:
- write down all of the negative things you say to yourself for
a day ... get others to help you identify these
- write a positive follow-up to each of the negatives
- next, say something positive to yourself whenever you catch
yourself saying something negative
- finally, instead of saying the negative thing, say something
positive ... don't fix it after - fix it before you say the negative thought


April 27, 2009
Living with Post Traumatic Stress Disorder and Depression
It seems like I've been diligently
working for seven years to recover - as well as experience personal growth and when things go downhill fast they cause me
to crash and burn over a long period of time. I still haven't been able to match up the facts that I've learned with the changes
that need to be made for a healthy environment with healthy relationships so I can control my PTSD and depression symptoms
more easily. I think that's what's making me crazy. I know what needs to be changed but I'm not responsible for making all
the changes that need to be made.
It's so hard when you're only half of the equation. It's hard to not make excuses. It's hard when your husband
doesn't understand what your symptoms are. It's hard when you're lonely. I've been avoiding too many important things in my
life - really important things - financial things. I've been hiding it from my husband and today I was so sick of it all that
I marched my butt downstairs and just blurted it all out. He was yelling at me - which triggers me terribly - I still cower
with fear. He yells at me no matter how big or how small the problem is between us. This is something he has to change. He
did better this time. He yelled only for a very short time. It was serious and I can understand his being upset.
I'm so used to receiving conditional love. I just expected him to tell me that things were over with us.
I warned him that he might want to ask me to leave, but he didn't go there - even for a second. This type of positive reinforcement
is something I really need. I want to be able to tell him everything I think and do, but I have never felt safe with him.
He's very narcissistic. He's paranoid. He thinks I do things just to hurt him. That's why he doesn't get what PTSD and depression
are all about. I've only told him so many times, but I have to keep telling him.
I wonder though if the reason he doesn't want to split up with me is because he needs me. He's very co-dependent.
He's a recovering alcoholic for 20 + years. Sometimes though I halfway expect him to come home drunk when he's mad at me for
something. I expect him to blame me for making him drink. We're so dysfunctional.
But avoidance behavior is still my modus operandi ... is that how you spell it? I can't deal with things.
My phobias are just as bad as they ever were. I can't open mail if it looks important. I can open the bills, or personal correspondence,
but I can almost never open anything that looks official, so I hide it. If I don't see it I can avoid it and try to forget
about it. There's only one thing worse than hiding it hoping to forget it .... and that's the consequence you end up with
after hiding it and avoiding it too long. Believe me... I've graduated up the ladder of avoiding important things.

So how did I relapse after getting better about avoiding things?
My son got hurt badly. He was playing pool with a guy and the guy lost the game and owed my
son 20 dollars. So he gave my son the money and then punched him - trying to connect with his face. This threw my son off
balance and he landed on the floor, pulling down a bunch of his friends on top of him. The guy who lost the pool game, he
grabbed my son's arm and twisted it. He ruptured the main artery in my son's arm and tore all the muscles and ligaments. It
was a very serious injury.
They had to take part of the artery in his leg to replace it in his arm. His father was very abusive with
me and the kids. He used hostile aggressive parenting methods and parental alienation. He had an affair with my best friend
and they ended up getting married. He thinks he controls every move my son makes. My son is very paranoid about being controlled
- especially since he's twenty-five.
I was exposed to that abusive nature though when I wasn't called by him to tell me of the injury. My son
called me as he was being wheeled into the operating room. We live six hours driving distance away from each other. It was
a triggering event of violence and injury and abusiveness which set off my PTSD.
It's another trigger that no one understands that these things trigger me. Everyone expects me to be normal.
I'm not normal. I have a mental illness. It's very frustrating for me. So time goes by and I'm not getting better with the
PTSD symptoms. Soon I feel as though my meds aren't working anymore.
I start going to counseling again and I know I'm regressing. I know everything that's happening to me, but
I can't stop it. This makes me even madder and more frustrated.
So... then we can't make our car payment. We start getting harrassing phone calls from some really ignorant
man at GMAC. He starts calling my neighbors when I won't answer the phone. He looks on the Internet and starts calling people
who have similar addresses as mine. He leaves messages with my neighbors to call GMAC because it's imperative that he talk
to me. He eventually takes our car after only 2 payments are missed on our lease.
The guy that is towing the car calls me in the morning and starts talking to me about my kids - calling
them by name. He wants to know if my son can help his mother do some work around her house. Two minutes later... the car is
gone. He used my kids names and told me right before he hung up that they were going to miss having a car.

At the same time or mortgage people stop taking the money
out of our account twice a month for our mortgage without letting me know. Suddenly things are really messed up because now
they're taking out a lump sum on the first of the month instead of only half of the payment. It makes my account bounce and
we end up in a cycle of paying fees and fees and then I can't make the payment because of the fees. It's crazy. I give up.
I avoid it.
We had never been late one time with our mortgage payment, in fact, they had lowered our interest rate when
they changed the way they took the money out of the bank. It lowered our payment about thirty dollars. Now I call the people
and tell them that I have PTSD. I tell them I'm triggered and I can't get with the program because I'm afraid of dealing with
it all. I'm going back into avoidance behaviors. They tell me to send some money. I say I will, but I avoid it.
Then it's six months goes by, then a year and now it's been over a year and our house is in foreclosure.
We've had money to pay the bill, but my head is so messed up because I've been changing meds throughout the year and we just
can't get it right. I can't make any decisions. My kids - teenagers - are having trouble in school. I've been babysitting
my grandkids non-stop. I don't have any control over my life. I can't even find time to go to counseling anymore.
Now I'm just avoiding everything unless I can't - like taking a shower and changing my clothes although
I dont' shower everyday now. I'm back to once every three days so you KNOW I'm out of control. I'm beginning to have very
negative feelings about myself. I want to tell the truth. I've been stuck too long. Today I decide I'm done with it. I march
straight downstairs and tell my husband to turn of the television. He doesn't turn it off, he just turns down the volume.
It's too important. It's the Price is Right.
Don't let yourself do this. It's extreme avoidance behavior and it will hurt you and others around you.
Now I'm starting over getting control of it. I have an appointment with my medication nurse practioner on Wednesday. It's
very difficult for me to admit these things to you all, but I want to be honest and I want you to know if you're doing these
things ... I understand.
Update: Surprise!
I've been working on avoidance behaviors and stopping them. I'm
doing well. Perhaps having a fresh start has been beneficial for one thing and that's not having anything to avoid. I
was lucky, very lucky. For this I praise God because the first house I looked at to rent, the landlord liked me and my son,
then my husband and made a conscious decision to rent to us anyway. I came right out and told him what happened without cutting
to any chase.
This doesn't happen all of the time in fact, the opposite happens more
times than what happened to me. So the first month came to pay the rent and I paid it a week early because I could and I wrote
the landlord a note telling him what was going on here at the house and the jobs my husband had done to the house to improve
it. I told him that we met the neighbors and everyone is getting along fine. I just didn't want him to be nervous about renting
to us. Lord help me if I cause anyone else the same anxiety and avoidance that I experience!
My relationship with my self is improving because I am being aware and mindful moment by moment. I am trying
not to avoid things - any things at all - which at the moment is the one thing I hate doing more than packing and that's unpacking!
So I take it little bit by little bit and that way I'm not avoiding, I'm just not diving into it full
scale. I can handle this. I'm hoping that day by day I'll be able to handle a little more. I have to say that the way we moved,
filling dumpsters full of junk I avoided throwing away for over fifteen years - is refreshing. Anything we didn't use in a
few months we dumped and thank you God. Unpacking is at least less daunting than it could have been.
I'm paying the bills when I get them in the mail immediately. So I am not avoiding the mail which is my
biggest phobia. I'm working on it daily. I have been sorting through important papers and organizing things. I have bought
three big binders and a hole punch to make scrap books for the kids with all their papers they accumulate over the years that
I didn't throw out because I just couldn't. But they are getting organzed slowly. I make myself work on them once a week.
The kitchen is done. I am trying to stop avoiding finishing projects which was a problem with me as well.
I'd start something and then avoid finishing it. I finished the big picture I did for the kitchen and it's almost completely
decorated in that room as well as the living room. I have one more wall in there!
So life can go on with an avoider. I'm working on my relationships as well. Oh... I went to the doctor at
the sleep clinic and this weekend I go to get my CPAP machine. I had the sleep test a year ago and avoided getting the machine
for a whole year - SEE HOW I ROLL?
The doctor made it clear to me that the first day I avoid using the machine I might as well bring it back
because I will avoid it more and more until I don't use it anymore. I am severely sleep deprived and have been shown on my
test to only receive 50% of the oxygen I need while I'm sleeping. So... okay I am not going to avoid the CPAP. Shoot imagine
how well I'll do with more than three hours of sleep a night?!
I'll keep you all posted, but it's coming along!

What causes avoidance behaviors? Sometimes
it's experiencing a trauma or a crisis that causes us to experience an extreme level of stress. Included in the symptoms of
acute stress or post traumatic stress disorder - or just the initial stages of extreme stress - avoidance becomes a defense mechanism. It's easier to avoid what happened and what continues to happen that is associated with the trauma than to face it, embrace
it, process it, and resolve it by letting the emotions and feelings go that surround the trauma.
But... as avoidance becomes a desirable response
to stress it also brings more problems with it.


Acute Traumatic Stress Management
Whatever happens to us during
peak emotional experiences in our lives, the gifts of life and the losses of life, will
stay with us forever.
In the same way that negative experiences are etched in our minds, so too may the positive force of Acute Traumatic Stress Management. Having someone say and do the right thing, at the right time, can dramatically affect an individual's recovery.
It's important to realize that addressing emergent psychological needs in the aftermath of a tragedy doesn't require an advanced degree in mental health. In fact, the best help is often rendered
by people on the front lines - people who take the time to listen and say the right things at the right time.
However, it's important for caregivers to know what to say and do before they reach out to help others. Traumatic experiences, by their very nature, compromise our ability to think clearly and often leave us feeling out-of-control. By having a plan, a traumatic stress response protocol, caregivers will be in control. They'll know what to say and do. They'll be prepared.
Beyond having an understanding of traumatic events and traumatic stress, caregivers must be equipped with practical tools that they can use to help others in the face traumatic exposure. This is
the primary goal of Acute Traumatic Stress Management (ATSM).
ATSM was developed as a 10
stage model in order to provide structure during an unstructured period of time - and to enable caregivers to "read off the
same page."
i.e., if I was helping an
individual to remain in a functional state, by focusing on the facts of a given situation, it would be unfortunate and potentially
problematic for another caregiver to walk over and ask, "How ya feeling?"
In fact, this situation was
described to me by a New York City police officer in the wake of September 11th. He reported that he was talking with a colleague
about extricating bodies when, "...some nut in a red jacket came over and asked me how I was feeling.... I told him to get the ____ out of here. I wanted to kill the bastard!" There's a right thing to say and a right time
to say it.
Following, is a brief overview
of the 10 Stages of ATSM. For additional information, caregivers are encouraged to read Comprehensive Acute Traumatic Stress Management (www.ATSM.org).
Noteworthy, is that ATSM was
built on a strong, empirically-based foundation. The first 4 stages of this model are of primary importance to emergency medical personnel and have to do with considerations surrounding situation management and emergency medical
care. The latter 6 stages may be implemented by all caregivers.
It's important to recognize that time constraints and the intensity of individuals' reactions, will vary. Consequently, appropriate intervention may
not fall neatly into a linear progression of stages. Caregivers will need to be flexible given the presenting circumstances.

1. Assess for Danger/Safety for Self & Others
Upon arriving at the scene,
assess the situation in order to determine whether there are factors that can compromise
your safety or the safety of others. You'll be of little help to someone else
if you're injured; i.e., don't enter a building that has obviously sustained structural damage. If possible, remove people
from the location in order to risk further traumatic exposure.
2. Consider the Mechanism of Injury
Form an initial impression
of those impacted by the event. In order to understand the nature of an individual's exposure, it's important to assess how the event may have physically impacted the person - that is, how environmental factors transferred to him.
i.e., if people are unconscious,
it's important to know what factor, or factors led to their loss of consciousness. It's also important to consider the perceptual experiences of victims.
i.e., directly observing the
bodies of children who have drowned will have a powerful impact on observers. Similarly, the sounds of people moaning will etch a lasting impression in the minds of all who arrive
at the scene to help.
Ask yourself whether it's
necessary for you to expose yourself to the inner perimeter. Direct exposure to a gruesome scene can compromise your ability
to address emergent psychological needs.

3. Evaluate the Level of Responsiveness
It's important to determine if an individual is alert and responsive to verbal stimuli. Does he feel pain? Is he aware of what's occurred, or what's presently occurring? Is he being influenced by a substance?
In the aftermath of Rita and Katrina, it's quite
possible that people are experiencing "emotional" shock. Therefore, symptomatology may mimic acute medical conditions (i.e., rapid changes in respiration, pulse, blood pressure, etc.). Recognize that a psychological state of shock may be adaptive in preventing the individual from experiencing the full impact of the
event too quickly. Keep in mind that during traumatic events, people can experience a wide range of emotional reactivity.
4. Address Medical Needs
Emergency responders are trained to assess the
ABCs (i.e., airway, breathing & circulation). They understand that if a man isn't breathing, there will be little else that can be done to help him.
Emergency responders also understand the importance of addressing significant symptoms (e.g., severe chest pains) as well
as the importance of knowing about existing medical conditions (e.g., diabetes). They've
also been trained to know the kinds of injuries that may present a threat to life (e.g., internal bleeding).
It's critical that medical intervention be provided
by trained emergency medical personnel. Consider the potential danger of moving a young woman who is found trapped under rubble.
Despite the best intentions of caregivers, the woman may have suffered a back injury and movement could cause permanent injury to her spinal cord. It's
imperative that life-threatening illness and injury are addressed prior to psychological needs.

5. Observe & Identify
Observe and identify those
who've been exposed to the event. Very often, these individuals will not be the direct victims. They may be secondary or hidden
victims.
As I stated previously, witnessing,
or even being exposed to another individual who has faced traumatic exposure, can cause traumatic stress.
As you observe and identify
who has been exposed to the event (i.e., directly &/or indirectly),
begin to observe and identify who is evidencing signs of traumatic stress.
An awareness of the emotional, cognitive, behavioral and physiological reactions suggestive of traumatic stress is important. Carefully look around you.
Anyone, including yourself,
may be a direct or hidden victim. This observation and identification stage of ATSM may be viewed as the first traumatic stress - specific stage.
6. Connect with the Individual
Introduce yourself and let
people know your role (e.g., "My name is Ron, I'm a social worker"). If
the individual isn't physically injured and he has been cleared by emergency medical personnel, move him away to prevent further
traumatic exposure.
Begin to develop rapport by
making an effort to understand and appreciate his situation. A simple question such as, "How are you doing?" may be used to engage the individual. Use appropriate non-verbal
communication (e.g., eye contact, body turned toward him, a gentle touch, etc.).
Recognize that during a traumatic experience, individual reactions may present on a continuum from a totally detached, withdrawn reaction to the most intense displays of emotion (e.g., uncontrollable crying, screaming, panic, anger, fear, etc.).
In view of the magnitude of
these hurricanes, you may likely find yourself working to connect with small groups of individuals.

7. Ground the Individual
When you have established
a connection with an individual or small group of individuals (e.g., eye contact, body turned toward
you, dialogue directed at you, etc.), you can initiate this grounding stage. Begin by acknowledging the hurricane at a factual level.
Here, you attempt to orient
the person by discussing the facts surrounding the event. Address the circumstances at a cognitive, or thinking level. While we don't discourage the expression of emotion, attempt to focus on the facts in the here-and-now and help the individual to know the reality of the situation.
His "reality" may be seriously
clouded due to the nature of the event. Remember, traumatic events overwhelm an individual's coping and problem-solving abilities. Assure him that he's now safe, if he is. He may still be "playing the tape" of the event over and over in his mind.
By reviewing facts, you may
disrupt "negative cognitive rehearsal" (i.e., repetitive, potentially destructive thinking), help the individual to function and enable him to deal with the circumstances at hand.
It's important to "place the individual in the situation." Encourage him to "tell his story" and describe where he was, what he saw, what it sounded like, what it smelled like, what he did and
how his body responded. Encourage him to discuss his behavioral and physiological response - rather than "how it felt."

8. Provide Support
Factual discussion and the
realization of a severe hurricane, may likely stimulate thoughts and feelings. This is often the time when individuals who are exposed to trauma need the most support.
However, in reality, it's
also the time when many people look the other way. Many individuals feel terribly unprepared to handle others' painful thoughts and feelings. Oftentimes, they fear that they'll "open a can of worms" or "say the wrong thing."
Generally, a reasonable attempt
to help others is preferable to avoidance.
It's important to establish and maintain a facilitative or helping attitudinal climate. Here, you attempt to understand and respect the uniqueness of the individual - the thoughts and feelings that he's experiencing.
You strive to "give back" a sense of control that has been "taken from" him by virtue of his exposure to the event. You support him and you allow him to think and feel.
Due to the magnitude of these
storms, many people will experience an overwhelming sense of aloneness and withdraw into their own world. You should make a respectful effort to "enter that world" and to help the individual to know that he isn't alone and that his unique perception of his experience is important.
Don't attempt to talk a person
out of a feeling (e.g., "Don't be scared, you're fine."). Communicate an appreciation of the other person's experience. Attempt to understand the feelings that lie behind his words (or perhaps actions) and convey that understanding to him.
While providing support with young children, you may need to hold and cuddle the child. Reassure him that he's safe, if he is. Know that children will take cues from adults around them, particularly those with whom they're close. It's therefore important to separate children, as quickly as possible, from all stressors - including emotionally overwhelmed adults.
Engaging children must be
made consistent with their developmental level; i.e., offering more information than a child is cognitively able to manage may do more harm
than good.
Recognize too that children, particularly young children, are generally unable to express their feelings verbally. They may likely convey their feelings through their behaviors/actions. If you have the time, providing children the opportunity to draw with crayons may be helpful.
i.e., you may encourage them to draw something that they remember about the event. The drawing may then be used as a vehicle to understand the thoughts and feelings the child's experiencing.

9. Normalize the Response
While you're attempting to support an individual by giving him the opportunity to express his thoughts and feelings, begin to normalize his reaction to the tragedy. This is an important component when intervening with people who've been exposed to trauma and who may be feeling very alone.
Experiencing a cascade of emotions, or perhaps a lack of emotional reactivity, may cause him to feel as if he is "losing it" and perhaps, "going crazy."
Normalizing and validating an individual's experience will help him to know that he is a normal person trying to deal with an abnormal
event.
It's important that you don't become sympathetic and over identify with the situation with statements such as, "I know what it feels like.... When I was...." Rather, you
should attempt to normalize and validate the individual's experience with statements like,
"I see this is overwhelming for you right now...seeing so much devastation would be hard for anyone to handle."
An important component of the normalization process is to begin to educate the individual by
helping him to know how people typically respond to traumatic events. Discuss the emotional, cognitive, behavioral and physiological reactions that people frequently experience.
Remember, these reactions
don't necessarily represent an unhealthy or maladaptive response. Rather, they may be viewed as normal responses to an abnormal event.

10. Prepare for the Future
The final phase of the ATSM
process is aimed at preparing the individual for what lies on the road ahead.
It's helpful to
1) review what we know about
the hurricane
2) bring the person to the present
3) describe likely events
in the future
The educational process initiated
during the previous Normalization Stage should continue during this final stage of ATSM.
Be careful not to tell someone as you near the end of your intervention that "everything is going to be okay," or that "everything
is going to work out." These kinds of "band-aid" statements may only serve to minimize an individual's feelings and cause him to feel misunderstood.
Instead, focus on the facilitative
attitudinal climate that you have established - "I'm glad that I had the opportunity to be here with you during such a difficult
time."
ATSM shouldn't be viewed as counseling or psychotherapy. Rather, ATSM provides a road map that can guide individuals through this horrific event, keep people functioning and
lessen the likelihood of ongoing emotional suffering.
Conclusion
In the aftermath of hurricanes Rita
& Katrina, our nation is rushing to address the devastating loss of life and destruction. Beyond the physical & safety needs of survivors, we must recognize and address the hidden trauma - traumatic stress. In this column, I've provided practical information about traumatic events and traumatic stress that should be reviewed by caregivers and shared with survivors.
Consider the potential of radio,
television and the printed news media in helping survivors to understand that their reactions are normal given such an abnormal circumstance? By educating people about traumatic stress, we can give survivors back a sense of control that these hurricanes seem to have taken away. Knowledge is power!
I have additionally presented
an overview of a traumatic stress response protocol, Acute Traumatic Stress Management (see www.ATSM.org). ATSM aims to keep people functioning and mitigate long-term
emotional suffering. By reaching survivors early, we can potentially prevent the acute traumatic stress reactions of today from becoming chronic posttraumatic stress disorders of tomorrow.
www.DrMarkLerner.com


avoidance learning
Avoidance learning is the process by which an individual learns
a behavior or response to "avoid" a stressful or unpleasant situation.
The behavior is to avoid, or to remove oneself from, the situation.
Researchers have found avoidance behavior challenging to explain, since the reinforcement for the behavior is to not experience the negative reinforcer or punishment.
In other words, the reinforcement is the absence
of punishment. To explain this, psychologists have proposed 2 stages of learning:
- stage 1: the learner experiences
classical conditioning; a warning, stimulus, paired with punishment. The learner develops a fear response when he experiences the stimulus
- stage 2: the learner experiences
operant conditioning; whereby he realizes that an action response to the stimulus eliminates the stressful outcome.

In a common laboratory experiment
conducted to demonstrate avoidance learning, a rat
is placed in a confined space w/an electrified floor.
A warning signal is given,
followed by an electric current passing thru the floor. To avoid being shocked, the rat must find an escape, such as a pole to climb or a barrier to jump over onto a
non-electric floor.
At first, the rat responds
only when the shock begins, but as the pattern is repeated, the rat learns to avoid
the shock by responding to the warning signal.
An example of avoidance learning in humans is the situation when a person avoids a yard
where there's a barking dog. This learning is particularly strong in individuals who've been attacked by a dog.
The problems of avoidance
Avoidance
is only easier in the short term - it usually creates greater problems later
on:
- Avoiding decisions
or action maintains tension and leaves problems unsolved.
avoidance behavior
can be the result of experiencing trauma

Avoidance
Symptoms
People who've been through
traumas naturally avoid reminders or events associated with the traumas. Sometimes they do this on purpose and sometimes they do this without realizing what they're doing.
However, persistent avoidance of some events can lead to other problems. i.e., a person
may begin to feel detached and estranged from other people. Relationships can be affected and a
sense of emotional "numbing" may occur.
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Different ways of avoiding
thoughts, feelings and sensations associated with trauma can include:
- Not
feeling physical sensations in the usual ways
- Not
feeling pain or other sensations
- Staying
away from trauma reminders
- Avoiding conversations, places, activities that might remind you of your trauma
- Lessened interest or participation
in activities that you used to do or that you would like to do
Avoidance
of thinking about trauma or seeking treatment keeps away distress but prevents progress on coping with trauma and its consequences. Avoidance can prevent people from seeking treatment for their trauma - related problems.

avoidance is a symptom
of post traumatic stress disorder, an anxiety disorder



How does trauma affect relationships?
Trauma survivors with PTSD often experience problems in their intimate & family relationships or close friendships.
PTSD involves symptoms that interfere with trust, emotional closeness, communication, responsible assertiveness & effective problem solving.
- Survivors may experience
a loss of interest in social or sexual activities, they may feel distant from others & they may be emotionally numb.
- Difficulty falling or staying
asleep & severe nightmares may prevent both the survivor & partner from sleeping restfully, which may make sleeping
together difficult.
- Trauma memories, trauma reminders
or flashbacks & the avoidance of such memories or reminders can make living with a survivor feel like living in a war
zone or like living with the constant threat
of vague but terrible danger.
- Living with an individual
who has PTSD doesn't automatically cause PTSD, but it can produce vicarious or secondary traumatization, which is similar to having PTSD.
- Significant others may come
to feel that dialogue & teamwork are impossible.

Survivors of childhood sexual & physical abuse & survivors of rape, domestic violence, combat, terrorism, genocide, torture, kidnapping, & being a prisoner of war often report feeling
a lasting sense of terror, horror, vulnerability & betrayal that interferes with relationships.
Although the survivor often
actually feels a strong bond of love or friendship in current healthy relationships, this experience can be perceived as dangerous.
- Survivors may be overly dependent upon or overprotective of partners, family members, friends or support persons (such
as healthcare providers or therapists).

In the first weeks & months
following a traumatic event, survivors of disasters, terrible accidents or illnesses or community violence often feel an unexpected sense of anger, detachment or anxiety in their intimate, family & friendship relationships.
Most are able to resume their
prior level of intimacy & involvement in relationships, but the 5-10% who develop PTSD often experience lasting problems w/relatedness & intimacy.
Yet, many trauma survivors
don't experience PTSD & many people in intimate relationships, families & friendships with individuals who have PTSD don't experience severe relational problems.
People with PTSD can create & maintain successful intimate relationships by:
- Establishing a personal support network
that will help the survivor cope with PTSD while he or she maintains or rebuilds family & friend relationships with dedication, perseverance, hard work & commitment
- Including playfulness, spontaneity, relaxation & mutual enjoyment in the relationship

avoidance of social
situations
a symptom of social phobia
or
social
anxiety disorder
Individuals
with social phobia typically experience symptoms resembling panic during a social encounter. These situations may include speaking in public, using public restrooms, eating with other people
or social contact in general.
The syndrome is considered
a disorder if it's severe enough to adversely effect social or occupational functioning. That is, individuals w/true social phobia go to great lengths to avoid social
situations, usually to their own detriment. The fear of embarrassment is ego dystonic & patients with social phobia are distressed by their symptoms.





click this underlined link to go there now! there's lots of additional "avoidance" information!
also there is more information at more emotional feelings
site about avoidance. click here to go there now!


New Twist in the Avoidant Attachment Style
When observing people with
the avoidant attachment style, psychologists have noticed a certain inconsistency across the group.
i.e., some avoidants have higher
self-esteem than others & they're less dependent. Researchers call this type of avoidants the "dismissing
avoidants."
The other group, the "fearful avoidants", fail to bond with others often due to lack of self-confidence & fear of rejection, but not lack of conscious attachment desire.
Recently, new hypotheses have
been formed to explain the differences between the "dismissing avoidants" & the "fearful avoidants".
Some researchers suggest that
these 2 sub-styles of avoidant attachment style share common early childhood roots, but sex-role socialization may have contributed to their later divergence.
Studies show that there are
more male dismissing avoidants & more female fearful avoidants.
Other psychologists suggest
the possibility that dismissing avoidants & fearful avoidants are two somewhat independent attachment styles, with different causes.



Ignoring or Avoiding Feelings
Using praise,
sympathy, humor, sarcasm or false reassurance are common ways people attempt to avoid
feelings.
Feelings
It's the essential ingredient
in effective communication. But we often avoid them in an effort to avoid the discomfort &/or pain that sometimes accompanies
them. It can be humiliating to admit that you feel hurt by another person's actions.
It can be painful to hear
your child express feelings of sadness or emotional pain. It's important, however, to allow these feelings to be expressed. It's critical that we become aware of how we avoid feelings so that we can eliminate that defeating habit from our communication style.
Avoiding pain
&/or avoiding feelings can lead to serious emotional problems that can last a lifetime. We do our children
a disservice when we resist expressing & experiencing our own feelings. It's also important to realize that feelings come in layers; like an onion, the feelings on the surface only a cover for the more tender feelings below.
Anger is often the safe feeling that we fall back on when we're
feeling intensely. Generally, the anger is only a cover for feelings that feel vulnerable. If we look underneath the anger, (either ours or our child's) we will find that the root of the
anger is hurt, guilt, sadness or fear.
Fear is the deepest layer of feeling that is masked by anger.


read how avoidanace
behaviors tie in with feeling frustrated - (click the underlined link words "feeling frustrated") read this article on the frustration page: Frustrations, threats & conflicts cause stress


Emotions That Challenge
Anger & fear are two of the most challenging emotions that teens, as well as adults, must face in a positive, healthy & constructive manner during peaceful times. In times of heightened national insecurity, the challenge is still greater.
Together with feelings such as guilt, hatred, jealousy & sadness, anger & fear are considered by many to be “negative” or “bad” emotions or feelings.
If you believe that anger & fear are indeed “bad” or “negative,” you might feel that you're bad or that something is wrong with you each time you experience
them. This may tempt you to stuff them or get rid of them
as soon as they surface in your life rather than accept & befriend them.
You'll also be
prone to feeling guilty when anger & fear get the best of you. When you “go off” in anger, especially, you may try even harder to stuff or get rid of these troublesome feelings.
Around & around
you go: Stuffed or rejected anger or fear leads to mistakes in handling. Perhaps you blow up at someone (anger) or refuse to take a healthy risk (fear). Then you feel lousy about yourself.

This causes you
to deny your feelings once again & the circle repeats itself.
Though anger & fear challenge you, trouble you & often involve pain, they're neither negative nor bad in & of themselves. They're simply part of your complex humanity
with a bad reputation, because of the circle I just described - one of destructive handling.
If you can begin
to view these two powerful emotions as natural, normal & potentially good rather than as negative, abnormal & always bad, you have a much better chance of managing them, rather than allowing
them to manage or dominate you.
The challenge for all of us - teens & adults - is to discover & practice healthy coping skills, so that unchecked anger & unchallenged fear don't lead us astray from the courageous & compassionate way of life modeled for us by Jesus Christ.
Anger Is Scary
Anger, your own or someone else’s, is uncomfortable. Other people usually don’t want to be around you when your anger is excessive or constant. It figures, since you usually don’t want to be around other people whose anger is extra-large or extra-long, do you?

Anger scares us all. Your own or someone else’s anger can come on suddenly &/or with unsettling intensity. You may be having a perfectly
fine day. Then someone - many times it’s a family member - can say or do something & you end up “losing it.”
Or you might say
or do something that results in someone else “going ballistic.” You (or they) might yell or scream or swear or slam a door & stomp off in a huff. Or you (or they) might use the silent treatment, sarcasm or put-downs as a way of unleashing angry feelings. Afterward, when the storm has passed, you are left with guilt, shame, remorse or embarrassment.
Anger, by its nature, is always going to be wild & powerful. Anger serves a very good purpose in your life, for it's often a response to injustice
or hurt, whether real or imagined.
So when another person treats you unfairly or with a lack of respect or if you believe someone has, anger is a normal, self-protective response. Not to feel angry in the face of mistreatment is to invite more of the same.
Oddly enough, many
people have trouble with anger that isn’t expressed often enough. For instance, you might frequently feel angry, but you may fail to deal with & release your anger energy in a direct manner. You let irritations & other little things that cause you to feel angry build up to the breaking point rather than addressing them as they occur.

You’re setting
yourself up for an explosion or rage attack. Often, it’s some little thing that causes you to “go off” on someone else, like the straw that broke
the camel’s back.
When you have reached
the “rage stage” or boiling point, your words & actions can become violent & out of control. You might say things you don’t mean or break things or even try to hurt someone physically, maybe even yourself.
If, however, you
can deal with your anger as you feel it or shortly thereafter, then it doesn't have to reach the rage stage. My wife & I have a loose “48-hour rule” in which we try to address conflicts, problems, unkind comments to each other within a couple of days.
Keep in mind that
anger is often a mask for fear. Anger leaves you feeling much less vulnerable than fear. In order to avoid the discomfort of
vulnerability, you may sometimes appear angry when, underneath the anger, you're really afraid.
Kevin, a high-school
senior, quite unknowingly uses anger as a self-protective mask for his underlying fear. He nearly always presents an angry image to others, which results in people keeping their distance from him.
Underneath his
anger is a fear of being abandoned by anyone he really cares about. This fear may very well be linked to the fact that his mother died of cancer when he was 7.

Fear Hides
Fear, in contrast to anger, is more of a hidden emotion. When people are angry, you can usually tell just by looking at them. It's more difficult to detect visible signs of fear.
Anger is usually about something that happened in the past, whether the event occurred just a moment ago or months or years
back. Fear, on the other hand, is nearly always about the future.
Sarah, who is 17,
experimented with alcohol for the first time at a party last weekend. Her fears aren't about the drinking, which is in the past, but about her parents’ reaction, should
they find out about it. This is in the uncertain future.
Fear can be healthy, as in the example of Sarah. Her fears are telling her that there are negative consequences, such as a loss of driving privileges, should she continue to drink in the future. In this case, fear is like a wise advisor or coach.
Fears can also be unhealthy. You probably know people who never take a healthy risk in order to have a happier, fuller life.

Steve has always
wanted to try out for a part in a play, but his excessive fears have prevented him from taking such a risk. In this case, fear can be like an overprotective parent who wants to, but can’t spare Steve the pain of possible rejection.
Fear often walks a fine line between being helpful & crippling. Perhaps we can view fears as being in a parade or progression from unhealthy to healthy. Initially, a fear might be unhealthy & extreme, only to become more healthy & moderate as you face it & deal with it creatively over the course of time.
Collective fears
Our nation’s
responses to September 11 are good examples of how we as a people experienced the full range of healthy & unhealthy fears. Right after the attacks, our country, quite understandably, was gripped
with overwhelming fear.
Citizens of Middle
Eastern descent, who had lived relaxed & normal lives prior to the attacks, became, overnight, among the people who were feared the most.

Fear led to anger. Mixed together in large amounts, these emotions can be a destructive mix.
On the news, you
saw some Americans dealing with their anger & fear by shooting at pictures of Osama bin Laden at local rifle ranges. At the other end of the spectrum, we saw reports
of some of our fellow Americans, who were just as angry & just as afraid, urging our government not to retaliate with violence.
The media reported
small numbers of Americans who reacted in unhealthy & destructive ways by attacking innocent Arab Americans. Other reports featured stories of compassionate & brave Americans who stood up for & befriended their grieving or fearful neighbors. All of us deal with anger & fear in a variety of ways, some of which are much more healthy & constructive than others.
Management Skills
Let’s look
at the skills professional people use to deal with emotion. If the manager of a particular business wants her employees to be productive & happy, she needs to develop a number of skills & traits, including these 4:
1) she needs to accept & value her employees as a team & as individuals
2) she needs to be firm yet gentle
3) she needs to be a good listener so that employees’ concerns & ideas are respected & honored
4) she needs to be the decision-maker

You & I need these same 4 qualities in order to manage our emotions, particularly the challenging, painful & upsetting emotions of anger & fear.
1.
Accept & value your feelings. Most of us have probably rejected our feelings of anger & fear as powerfully as people in Jesus’ time despised tax collectors & lepers. Jesus himself always accepted people as they were.
By valuing
each person, Jesus empowered those persons to make positive changes, to become whole, healthy people. You can do this with your powerful emotions.
2.
Be firm yet gentle with your feelings. Because anger & fear can be a bit wild & extreme, we need to be like the best of parents, coaches & teachers: firm yet gentle. You're firm when you choose not to act in destructive ways & choose not to allow fear to prevent you from taking risks that'll help you grow.
You
also should be gentle rather than “beat up on yourself.” Tell yourself: O.K., I just lost
my temper. I can’t undo what I just said or did, but I can forgive myself, apologize, make amends & try to do better next time. Or I’ve let my fears run wild this past week & have suffered because of it. I'll be kind & gentle to myself as I step out again in faith.

3.
Listen to your feelings & allow them to teach you.
Your
anger & fear simply want the basic courtesy of being listened to, acknowledged & taken seriously, just as you want others to listen to, acknowledge & take you seriously when you're sharing something important.
When
you feel angry (or afraid), you might simply sit down & ask, “What's my anger (or fear) trying to tell me?” If you do this, you may learn what you need to do.
i.e., “Hey,
you were mistreated by X & that’s not O.K. Go talk to him about his behavior. Tell him how you'd like to be treated
in the future so that I, anger, can move on & out of you.”
4.
Take charge of your feelings so that anger & fear don't inspire decisions they're unqualified to make alone. You don’t want your emotions to run the show of your life, to dominate you, especially when you’re upset. In my opinion, 7 key aspects (including feelings) make up a whole person. Each part has a role to play in your healing & wholeness.
These aspects of
your humanity can help you deal with all your painful emotions. You can call upon your faith & turn to God as a source of forgiveness & support. You can use your intelligence to help you think through situations, so that anger & fear don't have the final “mis-managerial” say.

You can exercise as a way of decreasing your anger & coping with fear. You can take action, even just a small step such as sharing your concerns with another person. This is particularly helpful in overcoming the paralysis of fear.
You can call upon
your heart & take courage, for it does take great heart & profound courage to live as people of faith in such uncertain times.
“Be stouthearted,
and wait for the Lord,” we pray in Psalm 27. This prayer can affect your attitude toward life, turning negativity & hopelessness into a positive & hopeful view.
Anger & fear are alive in our world. As followers of Jesus, your goal isn't to rid yourself of these 2 feelings, but to learn to live with & integrate them. As you act in ways that help this happen, you're participating in your own
healing & wholeness as well as that of our society, our nation & indeed, the whole world.
Gary Egeberg is a former religion teacher & the author of several books, incl.
My Feelings Are Like Wild Animals! How Do I Tame Them? He currently works as a Catholic chaplain in a California prison, where
his duties include helping inmates work thru their feelings of anger & fear. Bruce A. Hengstler
(15), April J. Ruppert (18), Kimberly Yahl (15) & Ryan M. Yahl (18), from St. John Parish in Fryburg, Ohio, took time
to review this issue on a Sunday morning after Mass. Ann Limbert, parish director of religious education, gathered the group.


How to avoid being labeled as
Average By graham and julie
When your life is over how will you be graded? Will you get an A or a B or will you
get a C Average? Will your time on this earth be rated as average? None of us want to be average. We all want to be successful. We all, deep down, have the desire to achieve something in our lives.
So why oh why are you satisfied
with being Ms or Mr average? What is it that makes you content being average?
What makes you average?
The
inability to say No. The need to back your life both ways The need to have another plan just in case. The need to appear a good guy. The need to be liked. The belief that I can’t change. The belief that I’m too old. The belief that it’s too difficult.
How do you avoid being
labeled as average in the world? Simple:
Choose what you want to do with your
life at this time and stick with it.
Now. Imagine someone is holding a gun to your
head and is demanding that you tell them what you really want to do with your life. What is it that comes out of your mouth?
Now ask yourself; what does this mean?
For example: I want to be a good parent....what
does this mean? It means that I want to focus all my energies to ensure that my children achieve their potential......Got
the idea?
Write it down. Is this really what you want to do? Are you really committed to doing this?
Because our gangster is still standing over you. If you don't start
taking steps towards making that happen, he'll come back. He knows who you are and what you promised, he just wants to see
you deliver. He'll be watching.
The two most important steps he's looking for are:
1. Do you have the right thoughts?
Your thoughts are important. Your thoughts can bring you untold success. But they can also destroy you. Doubt is guaranteed to stop you being successful. You must believe in yourself and your ability.
2. Are you taking Action?
Make the effort. If you don’t make effort you are left with the art of dreaming.
Dreaming of what might be one day.
Some of the most common excuses we have heard to avoid making
effort are:
-
It’s not the right time.
-
I was going to but “john” beat me to it
-
The market place is too full at the moment
-
The world is not ready for my idea yet
-
They forecast that there will be a recession this year.
-
I was thinking of it but they promoted me at work so…. Etc. etc. etc.
Whatever your action needs to be you need to start now. There is never a right time. There is only now. Whatever is past is past and thinking of what has happened can only cause doubt and stop you progressing.
You have no idea what the future holds for you so there is no point in trying to
second guess what may happen and build plans in case. You only have now. There is never any time but now and there never will be any time but now. Therefore whatever
you need to do to start to reach your goals has to be taken now in the job you are in or with the people you are with or in the situation you are in.
It is crucial that your thoughts and actions are fused together.
So just for a moment, sit quietly and meditate on what it is you want to achieve. Allow your thoughts to flow. Don’t edit your thoughts, just let them flow. Keep in your mind your goal and the way forward will gradually become clear to you. The secret to finding the right action is to hold your goal firmly in your mind at all times and ask yourself: What do I need to do now that will help me achieve this goal?
Don’t try to invent or create a way forward. Just stop and think. The way forward is most probably linked to what you are already doing. All you may need to do is look at it with new eyes. Look at your current actions in the light of your focus, your current goal in life.
To avoid being labeled average and have an
enjoyable and fulfilling life all you need to do is focus on your goal, keep focused at all times, believe you will achieve and take the necessary action as and when it presents itself.
Good luck Graham and Julie. www.desktop-meditation.com
To improve your intuition, initiative and energy levels please go to: www.desktop-meditation.com
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very important additional resources.....
The Dirty Dozen: 12 Relationship Red Flags to Watch For : "He's smart. Sexy. Fun. Sweet.
The total package. But there's just one little, uh, problem..." Now, it could take you months of dating to uncover
this (huge, relationship-wrecking) blip in your new boyfriend's behavior. But why wait?
To avoid romantic tragedy down the line, here are the 12 potential deal breakers to watch for now. The heart you save
may be your own.
The Psychological Aftermath of Hurricane Katrina: An Expert
Interview With Edna B. Foa, PhD
Posted 09/23/2005
Editor's Note: How does
recovery differ in natural disasters vs terrorists attacks?
What information do trauma survivors need most?
If they develop posttraumatic stress disorder (PTSD), what treatments work best?
To find out, Elizabeth Saenger, PhD, Program Director, Medscape
Psychiatry & Mental Heath, interviewed Edna B. Foa, PhD, Professor of Psychology in Psychiatry, Univ. of Pennsylvania,
Philadelphia, PA
Medscape: What
short-term psychological impact do you think Hurricane Katrina will have on residents of Louisiana, Alabama & Mississippi?
Edna B. Foa, PhD: Well, at
this point, many of the residents are so overwhelmed & confused, terrified & horrified. This is a very special trauma that has gone on for more than 2 weeks now.
In comparison, the tsunami,
i.e., lasted for several hours. Even though the devastation & death were horrible, people entered the posttrauma stage relatively quickly. This is what usually happens in earthquakes
as well, which may last hours, but even with the aftereffects of small earthquakes, the main event is over in a few hours.
In the case of Hurricane Katrina,
it's been days & it still isn't over. So people are still very confused & their psychological symptoms are not differentiated at this point. Now they worry about where they're going to be for
in the next hour or the next day - where they're going to get food & where they're going to be located next.
This is also true for the
people who have been evacuated who are still in temporary places.
So most survivors of the hurricane
are preoccupied with where they're going to get food & a roof. The psychological effect of the trauma will become apparent later on when people know where they're going to be located at least for a while. And then their reactions
will vary. Everybody will at least have anxiety symptoms for a while.
Who'll recover & who'll not will become apparent in the next few months. Most people will exhibit reactions to trauma, like anxiety, nightmares, flashbacks, disbelief, hypervigilance, difficulty sleeping & irritability.
We've heard about outbursts
of anger & irritability among those still in New Orleans, including incidents of rape & other behaviors that reflect anger & rage. For many people, these symptoms will gradually decrease & even disappear after they're settled. However, there will
be people for whom these psychological symptoms will become permanent.
Medscape: I've heard that poor people & black people were disproportionately
affected by Katrina both because they lived in areas that were more vulnerable
to flooding & because they were less likely to have the financial means to evacuate.
Do you think that would affect the way in which they recover?
Dr. Foa: Well, when people feel helpless & hopeless & lack the basic resources, it's going to affect their recovery. And to the extent that these people are feeling a lot less in control over their lives because of a lack of means, a lack of education & all kinds of other resources, they may be less likely
to recover & will have permanent symptoms of trauma.
And indeed there are data showing that people from lower
economic milieus are more likely to have PTSD.
Medscape: How do you think education might mediate recovery?
Dr. Foa: If education mediates recovery & we don't know that it does, it may be because education helps people develop a sense of being in control over their destiny, a sense that they can cope.
Also, if you're
more educated, you're more likely to figure out different ways of coping & you're less likely to feel helpless & hopeless. You're more likely to get a job, once you're located to another area &
figure out ways to adjust.
Medscape: What impact do you think Katrina will have on the rest of the country in terms of trauma? i.e., after the World Trade Center disaster, many people outside of New York felt traumatized
in some way.
Dr. Foa: Natural disasters are somewhat different from terror attacks. With respect to natural disasters, Katrina is an extremely horrible disaster & it can't be compared with other hurricanes.
People were exposed
to many horrific things during Katrina, perhaps more than people in the other hurricanes, which were also terrible, of course.
i.e., it was impossible
to evacuate, or the evacuation took much longer in this hurricane than evacuations in other hurricanes. Therefore, I think that we're likely to see more people with long-term psychological problems after this hurricane than we've seen in some other
natural disasters.
In general, studies show that
after a natural disaster, fewer people develop chronic PTSD than after combat or rape. Combat & rape are man-made as opposed to natural disaster. I view the disaster of September
11 as a combat situation since it was made by man & not by nature.
I don't really want to compare
whether people who were in the 9/11 tragedy or people who were in New Orleans & other places in the Gulf during Katrina
were more horrified, or less horrified. But I do want to
say that at 9/11, the evacuation started almost immediately after the event happened - there were no days of delay before
people started feeling that the country was behind them & everyone was organized to rescue.
I think that people who are watching the traumatic events on TV will have less of an impact from a natural disaster like the Katrina hurricane than from September 11 for several other reasons.
September 11 was totally unexpected
& unpredictable; hurricanes are expected. They're not controllable once they happen, but they're predictable. We know about them several days ahead of time & even know the areas that will
be affected.
We may not know how badly
a certain area will be affected, but we can start to evacuate beforehand. We are used to having hurricanes, even though we're
not used to having such a severe impact of a hurricane.
The people who aren't involved in the hurricane area may think it's terrible & identify with the people who are affected, but they don't feel that they may be affected themselves by
a similar event. In contrast, after September 11, our sense of security was shattered. We all waited for the next attack to
happen & we didn't know where it would happen next.
In that sense, people who were watching the World Trade Center
collapsing felt a lot more personally vulnerable, even if they weren't directly involved. After September 11, many people
feared for their own lives.
Several years have passed
since September 11 & because there hasn't been another major terrorist attack in the United States, we have regained a
sense of security, even though the government is telling us it can happen any day.
Medscape: Now can you tell me a little bit
about the treatments that work best for people who have been traumatized - people, e.g., with PTSD?
Dr. Foa: Well, you know, we don't really
know a lot about early psychological interventions; that is, what psychological treatment we should give immediately or shortly
after a traumatic event in order to prevent long-term psychological problems.
Common sense tells
us that we have to provide survivors with social support. We should help them get connected to the community because they need support from a community, via organizations like churches & community centers. They need to feel that they're part of a community & that they're not isolated.
However, we don't have studies
that show that evacuees who are integrated into a community will recover better than those who are not integrated. What we
do know from studies is that psychological debriefing - that is, asking people to talk about their traumatic experience shortly after the trauma - doesn't help to prevent future PTSD.
In the absence of studies,
we should use common sense in our early interventions, such as making sure that people get sleep, because sleep is very important for recovery, that they can reach out to their natural support systems & encourage them to reach out to wherever they can get community support.
Of course, people who show
extreme symptoms during or immediately after the traumatic experience that prevent them from functioning at all should receive psychiatric treatment as soon as possible.
For the remaining survivors,
it's extremely important to provide them with the information that if in 2 or 3 months, their symptoms of nightmares, flashbacks, avoiding reminders of the trauma, sleeplessness, outbursts of anger, &/or hypervigilance remain severe & disruptive, they should seek help.
After 2-3 months, survivors
will benefit from receiving treatments for chronic PTSD. We know that after 3 months, recovery rates slow down. And usually after a year, if severe symptoms aren't treated, they become chronic & natural recovery is unlikely to happen.
3 months is about the time
when, if the symptoms remain severe & impair the person's functioning, the person should seek treatment. Currently, we
don't know how effective group treatments are relative to individual treatments. Studies show that group treatment may be
somewhat helpful, but it's really individual treatments that were found to results in substantial improvement in most patients
with chronic PTSD.
Most effective treatments
for PTSD include an exposure component.
Medscape: Can you tell us a little more
about exposure therapy?
Dr. Foa: There are several programs of exposure therapy. The one we've developed has been widely used & also widely studied in several centers.
This treatment
program is called prolonged exposure therapy. In the first 2 sessions, patients receive psychoeducation that includes teaching them what the symptoms of PTSD are, why some people recover & others don't & why exposure therapy reduces PTSD symptoms.
The therapists also teach the patients how to breathe in a way that will relax them.
The therapists educate the patients about common reactions to trauma so that they don't feel that something is wrong with them because they're having these symptoms.
Some of the symptoms - like
the flashbacks, where a person actually feels as if he is in the middle of the trauma again - can be very scary & give the sense of going crazy. So educating patients is very helpful in the sense that it gives them a way to understand
their symptoms & put them in perspective.
The major part of the prolonged exposure therapy is asking patients to invite their memory about the trauma, think about it & describe it in detail.
The idea is that if people
have PTSD, it means that the traumatic memory hasn't been processed in a way so that they can deal with it, incorporate it into their
general life experiences by saying, "This was a horrible experience, but it's in the past & now I need to go on in life."
For people with chronic PTSD, whenever they think about the trauma, it feels like it's happening again. And so every time they're reminded of the traumatic experience, they get frightened & aren't able to process the memory & gain perspective of the traumatic event that happened in the past.
In exposure therapy, the patient
is inviting the memory & describes it again & again. These repetitions give the patient an opportunity to gain perspective,
to realize that they're describing a past experience & that thinking about the trauma isn't the same as being in the trauma. We do that every session.
The other goal of prolonged exposure is to help the patient deal with situations that they avoid. People with PTSD avoid a lot of things or situations that remind them of the traumatic event, such as going to the beach or being in crowded places.
Their lives get very restricted
because of these major avoidances. Some people don't leave their homes because they're afraid of every thing & every situation. People don't watch TV, read newspapers, or go to movies because they're afraid that there will be a story that will remind them of the hurricane.
So their lives become very
impoverished. They become dysfunctional, they can't go to work, they can't do what they need to do to become functional again.
In treatment, the therapist helps the patient identify situations that they avoid & that are important for them to confront in order to function. The therapist creates a hierarchy of these situations.
At first, we ask the patient
to confront situations that aren't so anxiety evoking & gradually, the patient goes up the hierarchy & confronts situations that are more & more anxiety evoking.
In this way, the patient finds out that he's avoiding situations not because they're really dangerous, but because he
doesn't want to remember the traumatic event or because he mistakenly thought that the situations were dangerous.
These are the 2 main techniques
that are used in prolonged exposure therapy. The first is called imaginal exposure, where we ask the patients to imagine the traumatic event & describe it.
The patient revisits the traumatic event again & again, since one time obviously won't help the person. The other technique is in vivo, in-reality exposure, where
the patient has assignments to go out & do things in the real world. We & other researchers have found that this treatment
helped at least 85% get much better. And 75% of the patients who receive the treatment improve so much that they achieve a remission.
The treatment involves between
8 to 15 sessions, but usually includes up to 12 & rarely 15.
We've also been able to disseminate
this treatment very successfully to therapists in the community in the US & around the world. This is very important because if the treatment can't be used successfully by other therapists, it's not of much use.
Medscape: I understand
you have a manual & that this is a very structured way of helping therapists use a technique that has been proven, that's evidence based to help people with PTSD.
Dr. Foa: Exactly. The manual instructs the
therapist about what to do in every session, so it's easy to teach because it's quite structured. And patients really like the treatment
because their lives are often quite chaotic & this treatment brings structure into their lives. In this treatment, there
are no surprises. The patients know what will happen in each session.
The beginning sessions are
somewhat varied, but from session 3 on, the structure is the same. Patients come to the session, the therapist asks them how their homework went, if they went to places they used to avoid.
Then the patient is asked
to revisit the traumatic event & retell it. After the retelling of the traumatic event, the therapist helps the patient process the memory, getting more & more perspective from the present into the past.
Because the sessions are similar
to one another, it's quite easy to disseminate the treatment. The last place we've been disseminating it was in the VA, teaching
the treatment to therapists who treat soldiers who returned from Afghanistan & Iraq.
Many of these returnees have
PTSD & it's important to provide them with an effective treatment that will ameliorate their psychological problems. If we can give the veterans
effective treatments as soon as they come back to the States, instead of waiting for years & years, then we can actually
prevent development of secondary problems like alcohol & drug abuse. Many people with chronic PTSD are medicating themselves with substances.
Medscape: So it seems that if you intervene
within the 1st year, you really save a lot of misery later.
Dr. Foa: Exactly. And we have effective treatments
that ameliorate the PTSD symptoms, so patients can resume their lives, they can go back to work & they can reconnect emotionally with their families & friends.
PTSD affects every aspect of life, including medical conditions. People with PTSD have more illnesses. They use medical services more. Also, their relationships with their families are disrupted & they
miss more days of work than people without PTSD.
So if we can identify Katrina
survivors with severe PTSD symptoms & impaired functioning once they're settled, 3-6 months from now & provide them with short-term effective
treatments, we can help them recover & prevent the secondary problems from developing.
Medscape: Well, it seems that we've covered
a lot of ground. Is there anything you would like to add?
Dr. Foa: Yes. Until now, I talked only about
psychological treatments. It's important to mention that medications such as antidepressants (eg, SSRIs) also help reduce PTSD symptoms in about 60% of patients.
Also, I want to
mention that our center at the Dept. of Psychiatry of the Univ. of Pennsylvania is very eager to help in training those people who are involved in helping the evacuees & other people who are affected by the Katrina
hurricane.
Medscape: Thank you very much, Dr. Foa.
Dr. Foa: You're welcome.
Edna B. Foa, PhD, Professor of Psychology
in Psychiatry, Univ. of Pennsylvania, Philadelphia, PA
Elizabeth Saenger, PhD, Program Director, Medscape Psychiatry
& Mental Heath
Disclosure: Edna B. Foa, PhD, has disclosed that she has received grants
for clinical research from Pfizer, Solvay, Eli Lilly, Smith Kline Beecham, GlaxoSmithKline, Cephalon, Bristol-Myers Squibb,
Forest, Ciba Geigy, Kali-Duphar & the American Psychiatric Assoc.. Dr. Foa has also disclosed that she has served on the
speakers' bureau for Pfizer, GlaxoSmithKline, Forest & the American Psychiatric Assoc.
Disclosure: Elizabeth Saenger,
PhD, has disclosed no relevant financial relationships
You want to avoid your
wife...
Whenever we avoid something we usually have clear reasons. Unpleasantness, pain, boredom. But there are also times when our reasons for avoiding aren't so clear. There are times when our motives for avoiding someone or something come in the form of feelings which don't have a clear logic to them.
Those
times we just feel we need to get up & leave a conversation, or when we don't know exactly why, but we're uncomfortable when someone wants us to do something for them, are the kinds of interchanges that can build up
within marriages & lead to long term hard feelings.
Marriage
relationships are challenging emotionally. Add children, & they become even more challenging. Because our marriage relationships are so challenging, especially when parenting is involved, there's an almost constant process of questioning, correcting, defining & redefining.
Because
we men are raised not to compromise, but to win, this evaluation process can easily result in feelings which are difficult & lead to misunderstanding, anger or hurt. Often our experience as men leads us to avoid anyone
who wants us to compromise or be involved in situations where we can't win .
What are we really avoiding?
As husbands
& fathers when we avoid our wives the reasons
for moving away aren't always what we think. More often than not our avoidance is part of
feelings which aren't all that clear, but are sure uncomfortable.
The coaching
in this website is that discomfort in relationships is something to
move towards, not away from. By moving towards the discomfort, by recognizing & talking about it, we're moving towards its source & ultimately its solution.
But as good strong men who have learned not to expose our discomfort, we naturally are inclined to hide what's going on inside of us. And when we feel
discomfort in response to our relations w/our wives & we want to avoid what's going on inside of us, this means avoiding
the source of our problem..........THE WIFE.
Perhaps
we could make this an Olympic event since it's so popular. Every guy does it. Avoiding
the wife is almost a right of manhood. Avoid
her, hide our feelings. Go away. It almost feels, well..... powerful. If if weren't for the fact that there's this pain in our guts as a result. And that we still have an
upset partner somewhere.
Avoiding our
wives or avoiding ourselves?
One problem
w/avoiding our wives when we're feeling angry or hurt is that we're shortchanging ourselves too. When we feel discomfort & avoid our wives, we also choose to avoid
(not deal with) the feelings in whatever the situation is.
On
one hand we're simply staying away from something unpleasant. On the other we're passing up the benefit of knowing what our feelings were trying to accomplish for us. That's right.....what our feelings are trying to accomplish for us.
Our
feelings are a form of knowledge unfolding. Every feeling that arises has a goal in mind. And when we ignore or shut down our feelings, we ignore a message from a place within us that has only our best interests at heart.
Every feeling has a goal & when we don't delve into the what & why of our feelings, we bypass those goals which are inevitably growth focused, emerging from our spiritual centers. Even the pain & anger we ascribe to our wives is actually part of our natural growth, if we can only let it out &
understand that its real purpose is to help us express love.
Are we tough enough
to stay w/our feelings?
For example,
imagine a man who is involved in a chore like washing dishes. If his wife points out that he's left egg on a dish already
washed, he might get angry, feel judged & raise up the deflector shields to prevent any more incoming damage.
On the
surface he's doing what's logical & that's shutting off something that's painful. Who wants
to listen to criticism anyway?
But beneath his move to shut off his wife's (true) comment, is his fear. The anger he feels at that moment, the flash anger that shuts him off to her, is also an opportunity to work thru the illusion that his wife is attacking
him.
His feeling in that moment, a feeling of pain which he chooses to shut down, is an opportunity arising out of his
relationship w/his wife, to learn something about himself & the power he has to determine how he experiences the world.
Let's
say the anger he feels at that moment grows out of a fear of
making a mistake & being discovered, being judged & perhaps ridiculed. In an instant all those possibilities roll into one ball of knowledge &
emerge in him as.....fear.
And rather
than follow the fear to its source, rather than being able to admit that he's creating a scene in his heart & head
that's painful & sharing that w/ his wife....
"I feel like you're saying I'm no good"
....... he shuts it & his wife off,
battles the feeling back down from where it came & ignores it. And as part of that battle he avoids what
seems to be the source of the fear, his wife & his relationship with her.
Minutes
or hours or even days later, he may still be stewing about something he felt, something he imagined, w/out ever knowing if
she really was saying he was no good.
That's
a lot to experience in a moment at the sink over egg left on a plate. But that type of dynamic is typically what underlies
our tendency as men to avoid our wives. There is
something there which is uncomfortable & threatening. Those moments of avoidance aren't just a choice we're making to be somewhere else or avoid an unpleasant person, but rather an avoidance of
some part of ourselves that is asking for attention, love & growth.
Marriage & parenting as a place of growth or
atrophy?
All of
us naturally grow & adapt all during our lives. Relationships are the universal environment for growth. It's only in response
to relationships that we grow & it's also only in relationships that we choose to stop growing.
When we
stop growing it's because something in a relationship has convinced us to trade our spontaneous,
natural, emotional self for one which behaves in ways that get approval from others. With this type of compromise we delay,
slow & even stop our natural growth.
Taking Chances
On the
other hand, if we pursue our growth & follow our soul, thru our fear of disapproval, we continue growing. The guy at the sink above, if
he's truly free & courageous, can say to his wife's comment about the dish still being dirty:
"I suddenly feel very angry"
or
"When you said that it felt like you were attacking
me"
or anything that honestly conveys him, carries him out into the open, rather than being silent & sending him scrabbling
back into his darkened cave.
Of all
relationships the parent relationship is perhaps the most challenging. It's constant requirement of communication about what's best & the ongoing redefining of baby's
constantly changing needs means lots of mistakes, delays & misunderstanding.
And because
of these challenges fathering is the best place to work on continuing our personal growth. It¹s here, where our children
& spouse are all to ready to voice their displeasure w/us that we're
offered the chance to grow.
If we're
able to deal w/our feelings & the people who evoke them, we can work our way thru our fear, both old & new. All of life's growth requires that we face our
fears. For men, for fathers, our most challenging work is in the arena of our feelings & the fears we've learned about expressing them.
For fathers
the hard work of personal [development] within parenting means staying in situations &
conversations as they become increasingly uncomfortable. Avoiding them avoids our truths.
These
moments of discomfort, which quite often flare into fights or flight
are opportunities to grow if we learn to stay w/ our feelings & resolve the problem, rather than tucking tail & avoiding.
Avoid our wives,
avoid our kids
A final
point about avoiding our emotional difficulties with our wives.
It's important to recognize that emotional avoidance can easily become
a habit & way of interacting. If we regularly follow the impulse of avoiding
or shutting off our tough feelings w/our wives, we will also be likely to follow that same impulse w/our kids when emotional
uneasiness arises w/them.
When we
hide &/or avoid our emotional
discomfort w/our kids, not only do we stunt our own growth, but theirs as well. Each time we hide
our feelings & avoid the
possible discomfort involved in being
truthful we take away from our children a chance to have their fathers
teach them, by our example, what happens when we're open to our feelings.
We rob
them, by avoiding our feelings, of learning how to deal w/their own tough
feelings. If we want our kids to treat us & others well, even though they may be
upset, then it's up to us to show them how.
To get
to a place of standing strong in the face of what feels like emotional danger requires a great deal of courage. Developing the courage can be aided & shaped by the [discipline] of practice. As
often as possible, rather than avoid our wives and/or children,
rather than hide our feelings, we can be truthful about what's going on moment to moment & courageously step into the unknown. (Be sure to read about [emotional boundaries] w/children, because not all feelings are appropriate to share with kids.)
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Relationship Matters Column by Offra Gerstein,
Ph.D.
Tools for Couple HappinessAvoiding resentments in relationships
Avoiding resentments in relationships
Resentments are simmering coals of anger, which gradually blacken a loving heart. The fire within these feelings is contained & subdued, yet may unexpectedly burst into flames of rage. In Nietzsche’s words,
"nothing on earth consumes
a man more quickly than the passion of resentment".
For many
couples the cumulative damage of non-extinguished resentments leads to irreparable damage.
The
goal in healthy interactions is to deal with arising hurts so that they don't mature into full blown resentments.
Feelings of resentments arise from the perception that one’s needs, from ordinary to serious ones, are disregarded
or violated. The injured party feels a deep sense of insignificance at not being seen or heard.
In times
of special need, the lack of support
is often viewed as a deep & even unforgivable betrayal. It may be perceived as the ultimate proof of one’s deepest fears about not mattering. To some people it feels like a mini-homicide.
In my
practice I've heard partners talk about a profound shift in their relationship because of a "deep betrayal". Some women see their husbands unavailability at the birth of their child as a major unforgivable abandonment.
In parenting
a special needs child, some spouses develop resentments about the reactions or behavior of their mates. Others painfully relate their partners
non-supportive attitude in the care of an aging parent.
Some speak
of their disappointment about their mate's responses to a disabling or life threatening illness.
Grieving couples, handling a loss of a parent, sibling, child, a job, or even a beloved pet, may find themselves
deeply hurt by each other’s inappropriate conduct.
Not only
do major life cycle events, when handled poorly, produce resentments. Many minor unmet needs also create a basis for feeling unloved. Thoughtless reactions, forgetful oversights & insensitive comments may be used to inflame resentful feelings. Keeping your partner’s needs foremost in your mind helps reduce the chances that resentful emotions may be born.
Resentments are often recorded, stored & not shared. As they accumulate, they slowly erode the
trust, an essential ingredient of committed love. The loss of trust in a having an feeling available, being available, supportive partner breeds a sense of loneliness, fear & the need for complete self-reliance. These feelings may lead us to questioning the value of
the partnership.
Much of
the destructive damage done by accumulated feelings of resentments is internal & secretive. Many
spouses are shocked to hear the list of grievances by their partners.
Many
live for years, unaware of the quietly burning resentments against them. They may be aware of a growing distance, detachment & perhaps intermittent outburst of specific anger without absorbing the depth, duration & intensity of their partners hurts.
The practice
of concealing these resentments is unproductive & unfair. It doesn't allow the "resented" partner an opportunity to help alleviate the mate’s pain, apologize for wrongdoing, explain or clarify his conduct, or learn about his hurtful ways.
It's analogous
to being tried & convicted without a trial or legal representation. The "resenting" party has concluded that the
"resented" person’s conduct is evidence that he no longer loves her.
She
may withdraw, be unkind, punitive or unloving. While one or both partners may be oblivious to the underlying reasons
their relationship is in ruin.
On occasion, the person holding the resentments is only vaguely feeling aware, feelings of awareness of the depth & damage caused by these old, unforgotten memories of pain.
Yet,
upon questioning, the angry hurts are easily elicited. It's very important to address every hurt feeling as it occurs, no matter how trivial it may seem, to help your partner understand
you better. Relating your painful feelings in a non - accusatory way will improve the chances that you will be heard & heeded.
i.e.,
"I felt hurt when you didn't introduce me to the woman we met at the store." Or "I feel
ignored when you continue to read the paper while I'm speaking to you". Or "I find it hurtful when the tasks you promised to help me with, get postponed for extended periods of time." These
sentences avoid accusations & state the feelings clearly.
Fortunate couples can recite contrary experiences to those cited above. They praise each other’s availability, concern & tenderness in their times of greatest need. They admire their spouse's capacity for the right words & conduct, for sensitivity,
patience & sacrifice. For those partners, love continues to grow, as each of them feels deeply seen, heard & honored.
How did they get there?
And how can you be equally successful in preventing resentments from ruining your love?
Ask your partner
frequently, whether he feels supported & loved by you. If he doesn't, clarify how you can better express your
love.
Make honoring your partner’s needs a high priority in your daily life.
Tell your partner
frequently how much you treasure him or her.
Ask your partner
whether she harbors any resentment. If she does, prepare to listen NON-DEFENSIVELY. Mirror her feelings, validate her perceptions & ask for forgiveness, if appropriate.
Decide
to be open about your hurt emotions as they occur. Don't suffer them silently. Sharing your feelings lovingly only makes you more intimate.
Once
both of you shared your old hurts, let them go.
Use your birthdays
to express your appreciation for the birthday person & your anniversary to enumerate the blessings of your union.
Realize
that what you may resent is the behavior, not the partner.
Avoid concluding
that your partner’s behavior means that you aren't loved. It's often a wrong conclusion.
Your partner
loves you, if his behavior doesn't exhibit it - he may need your help in better expressing his caring.
Redirect
the fire in your love, from simmering resentments to honest sharing of your feelings. Freeing yourself from accumulated hurts, will open your heart to a more deeply felt love.
Offra Gerstein, Ph.D., 3333 Mission Drive,
Santa Cruz, CA 95065 ,Phone: (831) 476-7666 - Fax: (831) 479-7005 © 2003 RelationshipMatters.com
I'm the "Queen of Avoidance"
I have to tell you, I'm really the Queen of Avoidance. You may know me as the keeper of the emotional feelings network of sites,
but truly, deep down inside, I am undeniably the Queen of Avoidance,
without a doubt in my mind. There are none better at avoidance behaviors
than me... myself & I.
I realize it's a strong statement to make, perhaps
not the most positive statement one might make about their own self, but it's the truth. I've come to realize the truth & I'm not denying it anymore. I am not living in that level of denial anymore.
Avoidance & denial are like kissing cousins. You can't have one without the other. If you're wondering why you keep
avoiding things & it makes you angry with yourself, or disappointed in yourself or just plain frustrated with life, you can bet your life I've been right beside you doing the same thing.
I've heard people say that
you can't fix what you don't acknowledge. Well... I acknowledge that I am in "avoidance mode" almost every minute of my day. I only want to do one thing,
avoid everything except the one thing I like to do - which is working on my websites.
I've been able to sit back
though, recently now that my sense of awareness is becoming much more developed - to see the effect of my avoidance behaviors on everyone
in my family. It's not a pretty picture! I have to young teenagers that are driving me crazy, but it's all the result of me
avoiding dealing with them. My husband is always accusing me - blaming me - for not taking the bull by the horns & becoming consistent with them & their discipline.
I know where this ends up.
These two teens are the younger generation in my family as I have 3 adult children as well. I also have a teenage step daughter
& another adult daughter. My life is full of drama, but I chose to avoid it at all costs.
"You want to go skating? Yeah, here's the money, I'll take
you."
"I thought she was grounded!" my husband yells out.
"But I don't want to hear her whine..." and he gets so mad
at me I can hear him begin to growl... "Kathleen... you're going to be sorry!"
Yeah, I know. I was sorry
this morning when my son wouldn't get up for school. He wanted to watch his show last night at 10 pm. I told him, you won't
get up for school in the morning if you stay up & he assured me he would.
I don't always do this,
I'm getting better, but how I started doing it, I really don't know. I guess everything was just too painful for me to deal
with at some point in my life, so I began to avoid!
Get with it
& stop avoiding things. I'm trying to quit it, but truly I am - the Queeen of Avoidance!
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