PTSD makes managing feelings extra hard. That is why we will look at ways to deal with different emotions.
But before we start with these steps there is one thing we need to take care of:
And that is hyperarousal (flight/fight response)
Hyperarousal (fight) is not anger, but the impulse for action might be similar, that is, hit someone. We cannot manage hyperarousal, which is a physical arousal level, with the psychological tools we use to manage emotions. The brain is in no condition to think clearly and make good choices, let alone process a strong emotion; we will most likely over-react. Before we even try to manage an emotion we need to get back within our window of tolerance. Only then can we look at the emotion that caused the hyperarousal and deal with it in a responsible way. Sometimes when the fight response is over we realize the emotion was never anger to begin with.
Before we try to regulate emotions we need to regulate arousal levels
Hyperarousal means that there is a lot of energy buzzing through our body, ready to be used for flight/fight. While with the flight-response this might show as a restless energy in the legs (for running away), the fight-response often comes with nervous energy in the arms (for attacking). It might be helpful to focus on skills that use the arms to lower arousal levels. That could be:
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push-ups
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trying to push over a wall
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or a person (who agreed to assist!)
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kneading clay/dough/a ball
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ripping old newspapers
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throwing sticks in the backyard
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trying to pull out trees (or just squeeze them really hard)
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lifting weights
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arm wrestling with a partner
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golf or baseball practice if available
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….
Whatever you choose to do, focus all your thoughts on the action, not on the trigger that caused the hyperarousal. We will deal with it later.
Now is the time to think of your Skills only.
Some people believe that hitting something in this situation is the best way to handle it. That is a double-edged sword. If done properly it can reduce arousal levels fast, but you should never mistake it as a way to regulate emotion. Teaching yourself that hitting is appropriate self-management might lead you into a court room. We aren’t even dealing with an emotion yet, this is all still about hyperarousal.
If you insist on hitting something, here is the safe way to do it:
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do not use your bare hands. You will hurt yourself. Grab a towel instead and make a knot in one end, to add a little weight there
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choose something safe to hit. That could be a bed, a pillow, couch, a bare wall or even the floor (if you use a bed you sleep in, maybe hit the lower end of it. Associating your bed with hitting can have a negative impact on the quality of your sleep) Choose, then hit that spot every time you use this exercise. This is to take away the struggle of deciding this anew each time you need it
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focus your mind on the action alone, take the towel and hit 5 times, hard. Breathe out while you hit, maybe count out loud
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take a break, check in with yourself, where is the arousal level? Do you need more? Continue if needed
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hit 5 more times, breathing out, counting. Focus on breath and counting and movement only, no other thoughts
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Take a break, check in with yourself, where is the arousal level? Do you need more?
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Repeat until you are out of the red area and ready to continue with Skills from the yellow area on the scale. Use your inner gauge.
If your thoughts keep drifting to the triggering situation/person, don’t continue with this exercise and use a different Skill (maybe containment) instead. You are just working yourself into a rage otherwise. The least helpful thing you can do is thinking of a person while doing a hitting exercise. Please believe me. It is a common myth, but it is still a myth.
Again: Do not confuse any of this with emotional regulation. When you calmed down it doesn’t mean that the emotion is dealt with or the situation is solved. It just means that you are now within your window of tolerance, not in a fight-response.
Now you are ready to look at your emotion and manage it. While you do that, make sure that you stay within the window of tolerance. If you feel arousal levels rising too high, please regulate yourself first before you return to this task. Managing emotions can be difficult, but it becomes impossible when outside the window of tolerance.
What is it you really felt there?
Help with identifying emotions
Managing the flight-response
Continue with managing a specific emotion:
Hi Theresa
Great to see you posting again.
As you indicate hyperarousal is purely physiological. It is a physiological reaction that occurs before cognition has a chance to process the situation and respond more appropriately.
Perfect for defense from Saber-toothed tigers. Some scientists have recently postulated that all our reactions are fear-based. Everything is built on this survival mechanism wired into our primitive brain.
In scenarios – and careers – where this response is likely to happen quite regularly; armed forces; first responders; etc., it becomes imperative that we find ways to deal with this hyperarousal. Repeated exposure to ever-increasing levels of psychological stressors teach us what this response feels like, and how to respond.
Repeatedly practicing gross motor skills while under pressure hard-wires our response mechanisms so that they become our go-to-skills in these situations.
However, this type of practice requires that one remove emotions from our reactions completely. We need completely different skills for processing those post-situation.
Thank you… Brett
We have been hip-deep in therapy work. And then there was halloween too.
Our T keeps us pretty busy, which is awesome, but we have to slow down with the blog.
Are first-responders taught how to deal with this? I would be interested in techniques that work for mentally healthy people.
For us it is important to speak about this and about the series we are trying to start here, dealing with different emotions.
We were raised without a hint on how to do this, with dissociation as our only solution. To heal means to choose different tools. It means learning a completely new skill-set that has no foundation in any childhood learning. It feels weird, fake really, to learn this so late in life. Mechanical, following 3 steps, 5 steps, 7 steps to managing an emotion. But it works.
Hi Theresa
Sounds like you have a great T there.
Yeah, in South Africa, First Responders are definitely taught how to deal with this. So, is LE, Fire Fighters, etc. But, then the environment requires it – it’s very violent on the Cape Flats. So much so that students travel from around the world just to get the exposure and to acclimatize themselves to the experience.
At first, the basic skills of the job are taught: diagnostics, pharmacological, electrical and surgical interventions are taught.
Then specific protocols are taught for specific scenarios: these involve Airway, Breathing and Circulation.
Then we start with some classroom patient simulations. Over-and-over the Instructor presents different scenarios to the class and asks for their response. At first, it’s a dog-show – everyone is all over the place. At the end of the simulation, we’re reminded of the protocols.
At first these patient simulations are fun and relaxed, but then the Instructor starts putting some psychological pressure on the student. Just that is enough to start the hyperarousal response.
After months of training, we had our own ‘Hell Week’. We had an abandoned building that had been strewn with hazards, and basically made to reflect the real-world environment. Patient simulations started to take place in this building. First couple of times, you walk in and fail before you even reach the patient. Then when you finally start working on the patient, you’re put under evidential time limits. Patient stopped breathing prior to arrival; you have less than 30 seconds to start chest compressions and respirations.
If you pass, you go out on a vehicle and you get exposed to the real thing. Usually, a senior practitioner monitors you, reminding you constantly of your protocols. I remember a very experienced Paramedic actually running the checklist through verbally on a patient before loading them for transport.
Sometimes the exposure is too quick, too real and the person bails. Don’t think, do as you’re trained.
I’d been working on the road for a couple thousand hours when my 6 week old infant went into respirator arrest at home one day. I went into Paramedic mode and the experience was probably the closest I’ve had to consciously and functionally dissociating that I can recall. My mind split: one part was focused on performing chest compressions and rescue breaths on him, getting the technique prefect, knowing that was the only thing standing between a successful resuscitation and losing my son. Another part of my mind was watching the clock, and planning my next moves: 2 minutes respiration; then down 5 flights of stairs with him; rescue breaths every 30 compressions; run up the road to the ER. In the background I was conscious of M*** crying and screaming. I ignored her completely – she wasn’t in danger and I didn’t have the time to comfort her. He was breathing again in 3 minutes.
Interestingly not many Doctors can handle working outside the ER. The ER is intense but it’s safe for them. They can’t handle the thought of a crawling into a burning car, upside down, or gang members pointing firearms at them.
One evening we brought a patient into the ER and another patient went completely psychotic in the ward. Patients, Doctors, security, everyone was in a panic. My partner and I walked up to the psychotic patient, tazered him and left. What was an overwhelmingly hyperarousal experience for the staff hadn’t even made our hearts race.
No one throws a soldier into a live-fire situation without preparing them; again with physical drills; then with friendly live-fire and finally with intent. The first round fired is a shock to the your system, literally, but after 10 000 rounds of live-fire, you don’t even notice anymore.
You know the concept of periodization in sports conditioning? Well, this is psychological periodization; progressive exposure to escalating levels of stress.
Breathing is probably the best go-to practice if things start to really get rough and you feel yourself moving out of your window of tolerance. The SEALS use a concept called Box Breathing: in for the count of 4, hold for the count of 4, out for the count of 4, hold for the count of 4, repeat. This has been borrowed from ancient practices developed by Eastern warriors.
“If you know the enemy and know yourself you need not fear the results of a hundred battles.” – Sun Tzu
WOW, thank you so much for sharing Brett!
A says it is another job we will never pick up, it sounds intense.
Now, after years of having to rely on DBT skills we often find that breathing is enough. It took a lot of practice to get there. Sometimes it is still not enough.
M is fascinated by the training. He will probably come up with something awesome based on this one day. take care!