Recovering from Workplace PTSD Workbook: A Recovery Workbook for Mental Health Professionals and PTSD Survivors [2 ed.] 9781699470053

Table of contents :
Cover
Copyright
Dedication
Table of Contents
ACKNOWLEDGEMENTS
AUDIOBOOK
COMPANION GUIDE
BOOK WEBSITE
PREFACE
INTRODUCTION
SECTION 1: UNDERSTANDING WORKPLACE REALITIES
Workbook Exercise 1-1: Does my occupation increase my risk of developing PTSD?
Workbook Exercise 1-1: Does my occupation increase my risk of developing PTSD?
Workplace Bullying, Harassment, and Discrimination
Workbook Exercise 1-2: Taking inventory of my workplace realities
Power Abusers Are in Positions of Authority
Workbook Exercise 1-3: Identifying my Power Abuser and the control tactics
Toxic Workplaces
Workbook Exercise 1-4: Am I experiencing a toxic workplace?
Synopsis
SECTION 2: IDENTIFYING YOUR REALITIES
What is PTSD?
Complex PTSD (C-PTSD)
Workbook Exercise 2-1: Understanding my situation
Workbook Exercise 2-1: Understanding my situation
Workbook Exercise 2-3: Identifying my emotions
Workbook Exercise 2-4: Am I anxious?
Workbook Exercise 2-5: Am I depressed?
Workbook Exercise 2-6: Am I having obsessive-compulsive thoughts?
Workbook Exercise 2-7: Describing the traumatic event that bothers me the most
Workbook Exercise 2-8: Am I experiencing a trauma reaction?
Workbook Exercise 2-8: Am I experiencing a trauma reaction?
The Brain and PTSD
The Health Impacts of PTSD
Additional PTSD Risk Factors
Synopsis
SECTION 3: BUILDING YOUR ACTION PLAN
Recovery Professionals
Finding Professional Support
Workbook Exercise 3-1: Building your coping strategies
Workbook Exercise 3-2: Five important questions to ask yourself
Workbook Exercise 3-3: Defining your S.M.A.R.T. recovery goals
Workbook Exercise 3-4: Build your wellness recovery action plan
Workbook Exercise 3-4: Build your wellness recovery action plan
Workbook Exercise 3-6: Researching my preferred recovery resources
Workbook Exercise 3-6: Researching my preferred recovery resources
Workbook Exercise 3-6: Researching my preferred recovery resources
PTSD Treatment Options
Synopsis
SECTION 4: GRIEVING, MOURNING, LETTING GO, AND MOVING FORWARD
Grieving
Grieving
Workbook Exercise 4-1: A conversation with your “inner child”
Workbook Exercise 4-2: What stage of grief am I in?
Workbook Exercise 4-3: Build your grieving self-care plan
Workbook Exercise 4-4: What stage of mourning am I in?
Workbook Exercise 4-5: Developing a new self-identity
Workbook Exercise 4-6: Managing a forced employment transition
Moving Forward
Synopsis
FINAL THOUGHTS
Building and Maintaining Your Network
Healthy Coping
Workbook Exercise 5-1: Healthy coping exercise
Monitoring for Signs of Potential Relapse
Workbook Exercise 5-2: PTSD relapse warning signs
Workbook Exercise 5-3: My relapse prevention plan
Managing Setbacks with Compassion
Finding a Healthy Workplace
Workbook Exercise 5-4: Healthy workplace checklist
Synopsis
REFERENCES
INDEX
WORKPLACE MENTAL HEALTH SERIES

Citation preview

Recovering from Workplace PTSD Workbook A Recovery Workbook for Mental Health Professionals and PTSD Survivors Workplace Mental Health Series Volume 2 Second Edition

Kevin William Grant

recoveringfromworkplaceptsd.com kevinwgrant.com

First published by SmartAir Media www.smartair.media Toronto, Ontario, Canada © Kevin William Grant 2019

The right of Kevin William Grant to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system, published, performed in public, adapted, broadcast, transmitted, recorded, or reproduced in any form or by any means, should be addressed to: Kevin William Grant kevinwgrant.com First Edition published July 2019. Second Edition published October 2019. Revision 1 Cover Image © Kevin William Grant Cover Design © SmartAir Media

Keywords: PTSD, Post-Traumatic Stress Disorder, Trauma, Recovery, Self-Help, Psychology, Workbook

ISBN: 9781699470053

Printed and bound by Kindle Direct Publishing Amazon.com, Inc.

To my partner, Ryan, and my mother, Helga, for their kindness, devotion, and unlimited support.

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Table of Contents ACKNOWLEDGEMENTS ....................................................................................................... IX AUDIOBOOK .............................................................................................................................X COMPANION GUIDE ............................................................................................................. XI BOOK WEBSITE ...................................................................................................................... XII PREFACE ................................................................................................................................. XIII INTRODUCTION ....................................................................................................................... 1 SECTION 1: UNDERSTANDING WORKPLACE REALITIES ............................................11

Introduction.................................................................................................................... 11 Workbook Exercise 1-1: Does my occupation increase my risk of developing PTSD?.......... 12

Workplace Bullying, Harassment, and Discrimination .................................... 18 Workbook Exercise 1-2: Taking inventory of my workplace realities ....................................... 32

Power Abusers Are in Positions of Authority ..................................................... 40 Workbook Exercise 1-3: Identifying my Power Abuser and the control tactics ..................... 55

Toxic Workplaces .......................................................................................................... 92 Workbook Exercise 1-4: Am I experiencing a toxic workplace? ................................................. 98

Synopsis ......................................................................................................................... 104 SECTION 2: IDENTIFYING YOUR REALITIES................................................................. 107

Introduction.................................................................................................................. 107 What is PTSD? .............................................................................................................. 108 Complex PTSD (C-PTSD)........................................................................................... 114 Workbook Exercises ................................................................................................... 117 Workbook Exercise 2-1: Understanding my situation ................................................................117 Workbook Exercise 2-2: Understanding my life situation .........................................................121 Workbook Exercise 2-3: Identifying my emotions.......................................................................125 Workbook Exercise 2-4: Am I anxious? ...........................................................................................140 Workbook Exercise 2-5: Am I depressed? ......................................................................................142 iii

Workbook Exercise 2-6: Am I having obsessive-compulsive thoughts? ............................... 146 Workbook Exercise 2-7: Describing the traumatic event that bothers me the most......... 153 Workbook Exercise 2-8: Am I experiencing a trauma reaction? .............................................. 155 Workbook Exercise 2-9: Could I be experiencing PTSD? ........................................................... 160

The Brain and PTSD ....................................................................................................164 The Health Impacts of PTSD ....................................................................................169 Additional PTSD Risk Factors ..................................................................................173 Synopsis .........................................................................................................................174 SECTION 3: BUILDING YOUR ACTION PLAN ............................................................... 179

Introduction ..................................................................................................................179 Recovery Professionals .............................................................................................180 The Broad Categories of Counselors .............................................................................................. 180 The Broad Categories of Psychotherapists ................................................................................... 181 Career Counsellors .............................................................................................................................. 183 Life Coaches ......................................................................................................................................... 184 Social Workers ..................................................................................................................................... 185 Psychologists ....................................................................................................................................... 186 Psychiatrists.......................................................................................................................................... 189

Finding Professional Support .................................................................................190 Step 1: Think About the Support You’re Looking For ................................................................ 190 Step 2: Gather Referrals ..................................................................................................................... 192 Step 3: Scheduling Your First Meeting .......................................................................................... 194 Step 4: Ask Questions ........................................................................................................................ 194 Step 5: Build a Professional Working Relationship ..................................................................... 195

Workbook Exercises ...................................................................................................197 Workbook Exercise 3-1: Building your coping strategies ......................................................... 197 Workbook Exercise 3-2: Five important questions to ask yourself ......................................... 211 Workbook Exercise 3-3: Defining your S.M.A.R.T. recovery goals ........................................... 217 Workbook Exercise 3-4: Build your wellness recovery action plan ........................................ 238 Workbook Exercise 3-5: How I would like support to be delivered........................................ 261 Workbook Exercise 3-6: Researching my preferred recovery resources ............................... 264 iv

Workbook Exercise 3-7: Selecting three local professional support resources ....................271 Workbook Exercise 3-8: Reaching out and scheduling an initial consultation ....................272

PTSD Treatment Options ......................................................................................... 276 Medications ...........................................................................................................................................277 Cognitive-Behavioral Therapy ..........................................................................................................278 Anxiety Management .........................................................................................................................282 Emerging Treatments .........................................................................................................................283 Complementary Treatments.............................................................................................................288 Preferred Treatments..........................................................................................................................291

Synopsis ......................................................................................................................... 295 SECTION 4: GRIEVING, MOURNING, LETTING GO, AND MOVING FORWARD ... 299

Introduction.................................................................................................................. 299 Grieving .......................................................................................................................... 300 Mourning ....................................................................................................................... 304 Workbook Exercises ................................................................................................... 314 Workbook Exercise 4-1: A conversation with your “inner child” .............................................314 Workbook Exercise 4-2: What stage of grief am I in? ..................................................................319 Workbook Exercise 4-3: Build your grieving self-care plan .......................................................323 Workbook Exercise 4-4: What stage of mourning am I in?........................................................334 Workbook Exercise 4-5: Developing a new self-identity ...........................................................338 Workbook Exercise 4-6: Managing a forced employment transition .....................................348

Moving Forward .......................................................................................................... 365 Synopsis ......................................................................................................................... 367 FINAL THOUGHTS............................................................................................................... 369

Introduction.................................................................................................................. 369 Building and Maintaining Your Network ........................................................... 370 Healthy Coping ........................................................................................................... 371 Workbook Exercise 5-1: Healthy coping exercise ........................................................................374

Monitoring for Signs of Potential Relapse ......................................................... 388 v

Workbook Exercise 5-2: PTSD relapse warning signs ................................................................ 392 Workbook Exercise 5-3: My relapse prevention plan................................................................. 396

Managing Setbacks with Compassion ................................................................407 Finding a Healthy Workplace .................................................................................409 Workbook Exercise 5-4: Healthy workplace checklist................................................................ 413

Synopsis .........................................................................................................................417 REFERENCES ......................................................................................................................... 419 INDEX ..................................................................................................................................... 433 WORKPLACE MENTAL HEALTH SERIES ......................................................................... 436

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ACKNOWLEDGEMENTS I want to begin by thanking my editor, Mary Ann Blair, for taking the time to tune and clarify my thoughts and ideas. Mary Ann provided essential views that strengthened the focus and narrative of this book. Psychotherapy and coaching private practice have contributed to this second edition with their feedback, requests, suggestions, journeys, and experiences. I thank all of the contributors for giving me the privilege of participating in their recovery and transformation. My family continues to be one of my most significant sources of support. I find great joy in the connection I have with my partner, Ryan; mother, Helga; stepfather, Dario; mother-in-law, Susan; and brother, Robert. To my partner, Ryan, for your ever-present love, support, creative inspiration, and listening. Some of the people who helped bring this book to life include the following: •

Editor: Mary Ann Blair

•

Design: SmartAir Media

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AUDIOBOOK The “Recovering from Workplace PTSD Audiobook” is an unabridged narrated version of “Recovering from Workplace PTSD”, available in hardcover, paperback, and eBook formats.

The “Recovering from Workplace PTSD Audiobook” is available on Audible, Amazon, Apple Books, and other audiobook sources. Look for the links and information on RecoveringFromWorkplacePTSD.com.

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COMPANION GUIDE This workbook is a companion volume for the “Recovering from Workplace PTSD” guide. You can complete all the workbook exercises in this book without the recovery guide; however, I recommend pairing this workbook with the recovery guide for the full recovery benefit and additional context.

The “Recovering from Workplace PTSD” guide is available in paperback on Amazon and in eBook format on Amazon, Kobo, and Apple Books. Lulu (lulu.com) offers this book in hardcover. There is an audiobook edition of this book. xi

BOOK WEBSITE Please send me your feedback and read supplemental materials on the RecoveringFromWorkplacePTSD.com website. Look for links on the website for more information about how to get a copy of the companion guide.

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PREFACE Recovering from Workplace PTSD Workbook is a recovery workbook for mental health professionals and PTSD survivors. It offers no-nonsense, practical advice and exercise to help empower PTSD survivors to build and implement their personalized recovery plan. I approach the complex topic of workplace PTSD from clinical psychology, life coaching, and corporate management perspectives. In the clinical psychology domain, I draw upon my experience as a Clinical Psychology Associate with a Master’s in Clinical Psychology, a Bachelor of Science in Psychology, and a Ph.D. Candidate in the field of Social and Personality Psychology. My coaching perspective originates from collaborating with clients as a Certified Professional Coach, certified by the International Coach Federation. The corporate management perspective comes from my work as a product manager at Microsoft, Mozilla, TD Bank, The Globe and Mail, and Bell Canada. I am a workplace PTSD survivor. Being a gay man who was out at work exposed me to harassment, bullying, and discrimination. This workplace trauma had a cumulative effect on me over two decades that ultimately transformed my recovery journey into a life mission of personally helping others recover from workplace PTSD. My clinical psychology skills and real-world corporate experience fit naturally with this mission, and I decided to research and put together this book. When I began writing, I had lofty goals and was driven by a sincere passion for effecting positive change. My personal xiii

experience with workplace PTSD inspired me to find my inner voice of courage and strength, and I hope this book inspires you to find yours. At its core, it will give you the tools and insights necessary for you to understand, confront, and heal from workplace PTSD. I wrote this book for individuals recovering from workplace PTSD and to inspire mental health professionals with new and emerging treatment ideas. The goals of this workplace PTSD recovery plan are to learn more about PTSD—what it is, where it comes from, and why it develops. The book will help you come to terms with the realities of the modern workplace so you can examine your experiences with a fresh and honest perspective and find clarity so you can journey into a peaceful, happy, and rewarding future.

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Introduction

INTRODUCTION Stress, anxiety, depression, trauma, bullying, and burnout have all become “accepted realities” of the modern workplace. This recovery workbook will unpack contemporary workplace realities, educate you about PTSD, and help you build your personalized recovery plan for transformation and recovery. This recovery program has six core purposes: 1. Validate your current situation. This recovery program begins by validating your experiences and breaking through any denial you may be experiencing by examining all the ways you could be traumatized at work. 2. Identify your realities. Once you understand how you’ve been traumatized, you’ll learn about how PTSD develops and how to break through the defenses that protect you from the painful experiences you’re facing. 3. Understand workplace PTSD. Armed with a deeper understanding of what PTSD is, how it develops, and how you react to trauma, you will be able to identify the support you’ll need to heal and recover. 4. Build your recovery team and develop your action plan. Useful tools and techniques will help you connect with and build your team of support professionals and advocates. Once you begin working with your team, you’ll start the recovery process by acquiring a set of skills and techniques to help you weather the storm and begin healing. 1

Recovering from Workplace PTSD Workbook

5. Grieve, mourn, and let go. Recovery will take you on a journey of grieving, mourning, and letting go, which will transport you to a new sense of calm and acceptance. I’ll break down this journey into the stages you’ll travel through to get to the other side. 6. Maintain your recovery. Finally, I’ll share helpful ways to maintain your recovery, manage setbacks with compassion, and track your progress so you can proactively navigate the inevitably choppy waters as you continue your healthy and productive recovery. Recovering from Workplace PTSD Workbook contains three central concepts: workplace, recovery, and Post-Traumatic Stress Disorder (PTSD). A workplace is a place where people are employed. Workplaces are incredibly diverse and span government offices, public transit, medical facilities, banks, for-profit corporations, and not-for-profit entities. They are typically organized into hierarchical power structures with employees neatly organized from lower- to higher-ranking individuals. Recovery refers to the process of healing from trauma by applying a variety of tools and techniques. Post-Traumatic Stress Disorder (PTSD) is a mental illness with significant impacts on an individual’s mental health. PTSD develops in some people who have experienced traumatic events, which include crimes, natural disasters, workplace abuse, bigotry, accidents, war or conflict, or other threats to life and self. PTSD can develop from a traumatic experience you experience or observe happening to others, such as witnessing a horrific accident. PTSD can also develop after a sudden and unexpected loss, such as the death of a 2

Introduction

loved one or the loss of a job. An experience is traumatic when it is incredibly frightening, overwhelming, and causes high levels of distress. Trauma is unexpected, and many people say they felt powerless to stop or change the event as it was happening. It is very common for someone with PTSD to reimagine the traumatic event after it’s over. Many people experience flashbacks, nightmares, and spontaneous vivid memories of the events that feel as if they come from nowhere. PTDS survivors often avoid things that remind them of the event—for example, an airplane crash survivor may avoid flying at all costs. PTSD can make people feel very nervous or on edge all the time. Many are easily startled, have a hard time concentrating, feel irritable, or have problems sleeping. They may also manifest feelings of dread, as if something terrible is about to happen to them, even when they know, rationally, that they’re safe. Others react by feeling numb and detached; they perceive things around them as not feeling real, as if they’re disconnected from their body or thoughts, or have a hard time feeling emotions. Another typical reaction is to self-medicate using alcohol or drugs. Scary and emotionally traumatic situations occur for everyone at some point in their lives. Individual reactions vary from person to person. Some people might feel nervous, others may have difficulty sleeping, and many ruminate on the details of the situation. These thoughts or actions are a healthy response. Typically, these reactions subside over time, and people eventually go back to their daily lives and move forward. PTSD, on the other hand, lasts much longer and can severely disrupt a 3

Recovering from Workplace PTSD Workbook

person’s life. Symptoms usually begin within three months of the traumatic incident, but they can take years to appear. They must last more than a month and be severe enough to interfere with a person’s life to be considered PTSD. Some people recover within six months, while others’ symptoms last much longer or become chronic. But not all traumatic experiences lead to PTSD. We aren’t sure why only some people are affected, but it’s likely linked to specific factors including the length of time the trauma lasted, the number of other traumatic experiences in a person’s life, their reaction to the event, and the kind of support they received after the event. Trauma doesn’t always refer to a single event in the past. Repeated or prolonged acts, such as sexual abuse, sexual violence, abduction, or harrowing experiences during wartime, can impact a person’s life far beyond the symptoms of PTSD. The term complex PTSD is used to describe these experiences. Recovering from Workplace PTSD Workbook is divided into four sections from self-discovery to recovery. Some of the sections may be more relevant to you and your situation than others. You can dip in wherever you like because each section stands alone. If you would like more information about a particular topic, the Index and Contents are great places to start. Section 1: Understanding and accepting workplace realities. Recovery always starts with an intuitive sense that something isn’t quite right. For some people, their lives can feel broken, and daily living becomes an uphill battle. This section inventories the most common realities of corporate life that 4

Introduction

contribute to or trigger extreme stress and trauma. My experience working in corporate environments and interviewing workplace PTSD survivors inspired this list. The purpose of this section is to validate your experiences and let you know you’re not alone. Section 2: Identifying your realities. This section will identify and define what you’re experiencing. Since recognizing you’re experiencing PTSD is the first step toward healing and recovery, here I’ll introduce the process of self-reflection and understanding. The impacts of workplace PTSD are real and can be debilitating. Understanding the underlying causes of PTSD will help you come to terms with your reality. Acknowledging and accepting your current situation will unlock and begin the healing process. Section 3: Building your action plan. Researching and selecting your support team is the foundation of an effective recovery plan. I begin by reviewing the different types of recovery professionals capable of treating PTSD. Next, I cover strategies for effectively researching and contacting local professional support options. At the end of this section, I teach you how to become a self-advocate, so you can clearly communicate your needs and wants and talk openly to your recovery team about your thoughts and feelings. Section 4: Grieving, mourning, letting go, and moving forward. Grief and trauma go hand in hand, and this section begins by exploring that connection. As you’ll learn, the PTSD recovery process is broken down into six stages of mourning. The grieving and mourning process helps us make sense of what happened to us and ultimately find a path forward. We form a 5

Recovering from Workplace PTSD Workbook

new self-identity when we let go of our past self and reach a place of calm and acceptance. At this point, we’re ready to let go and move forward with our lives. The “Final Thoughts” section covers self-exploration of this topic in more detail. Workbook Exercises will help you digest the content, reflect on your situation, learn from that reflection, and incrementally create a personalized recovery plan. Each exercise in the workbook walks you through a process of self-reflection and self-discovery to help you understand and make sense of your situation. Recovering from PTSD is a step-by-step process. Whether you want to make a change in the next couple of months or the next few years, this book is designed to help you achieve the following: •

Open your mind to creatively explore your PTSD recovery options

•

Identify and understand the triggered emotions that surface with your PTSD symptoms

•

Deepen your approach to life and your lifestyle needs

•

Define what you need in your work environment to feel healthy and happy

•

Outline your recovery action plan and personal recovery steps

•

Transform your passions and interests into a viable recovery plan

Creating a personalized recovery plan is an empowering way to actively participate in your recovery. PTSD is a severe mental 6

Introduction

health issue, and it is critical to find qualified support professionals. The workbook exercises are designed to be paired with the assistance of a qualified mental health professional with PTSD recovery experience. Later in the book, I systematically walk you through how to research and contact local support professionals. I recommend skipping forward to this section now if you feel you urgently need professional assistance. Support systems in your local community are ready to help you at any time. Take a break at any time if you find the exercise overwhelming or too painful to complete. You can always return to this exercise when you’re feeling better. When we’re trapped in a negative situation at work, it’s easy to lose perspective because we’re surrounded by toxicity daily. What initially seemed bizarre or crazy can evolve into resigned acceptance, denial, and a feeling of futility. We often feel a profound sense of relief when we realize we’re not the only person going through something. Whether it’s life stress, a significant life change, a physical or mental health diagnosis, or anything in between, we often suffer in silence, fearful that we will be misunderstood or considered different. A powerful technique applied throughout this workbook is normalizing your experience, which is the process of recognizing that an experience isn’t strange, unusual, unique, or shameful. Throughout your recovery journey, you’ll have an opportunity to understand and explore your experience from different angles. Part of being human is the desire to feel like you belong. By normalizing your experiences, I hope you grow to understand 7

Recovering from Workplace PTSD Workbook

yourself better and learn to manage your physical and mental health needs. Your recovery process is about realizing that others have shared similar experiences and that your reactions or symptoms are normal and real. I hope this recovery journey breaks down barriers and fosters within you a sense of openness and honesty.

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Introduction

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Recovering from Workplace PTSD Workbook

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Understanding Workplace Realities

SECTION 1: UNDERSTANDING WORKPLACE REALITIES Introduction Your career impacts your mental health in many important ways. A career that allows you to apply your unique talents and skills in a satisfying and personally fulfilling way spills over into other areas of your life in a positive way. A rewarding career enables you to express who you are and live the life you want. Sometimes, though, a job may look great in theory, but it clashes with who you are and how you want to live your life, and you cannot find a way to include your needs and desires at work. Our work environments are distinctly different from the contexts we live in with our friends and families. Switching between work and non-work time requires us to take on vastly different cultural and behavioral norms. The divergence between those two worlds often leads to cognitive and emotional conflicts within us. The first step in your recovery process is acknowledging the workplace realities contributing to your PTSD symptoms. The main goal of this workbook section is to help you identify those realities that are also seeping into your leisure time. You’ll review some workplace realities that are proven to contribute to the development of PTSD symptoms and identify their impacts. If you’re being abused or have experienced a traumatic event at work, you’re not alone, and many treatments and support 11

Recovering from Workplace PTSD Workbook

resources are available to support you through your recovery. If you’re experiencing extreme symptoms that are making your life difficult to manage, I encourage you to skip ahead to Section 3, which covers how to find the support you need. I hope that this workbook section brings you comfort, hope, and optimism by learning to more clearly understand your realities at work. My objective is to give you clarity on how your situation at work could be contributing to the development of PTSD symptoms and impacting your mental health. Your workplace PTSD recovery journey begins by seeing your situation more clearly and opening yourself up to finding the support you need to recover.

Workbook Exercise 1-1: Does my occupation increase my risk of developing PTSD? Goal This exercise will help you identify if your work puts you at a higher risk of being exposed to trauma and developing PTSD. Instructions Below is a list of high-risk occupations that expose individuals to trauma and increase the risk of developing PTSD.

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•

Identify if any of these occupations are relevant to you.

•

If any of these occupations are relevant to you, list the aspects of the work that expose you to potentially traumatic experiences.

•

Finally, describe the impacts of these potentially traumatic experiences.

Understanding Workplace Realities

Occupation

Applies List the aspects of your to Me work that expose you to traumatic experiences.

1.

Military and combat personnel

❑

2.

Law enforcement officer

❑

Describe the impact of these potential traumatic experiences on you.

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Recovering from Workplace PTSD Workbook

Occupation

Applies List the aspects of your to Me work that expose you to traumatic experiences.

3.

EMT/paramedic

❑

4.

Firefighter

❑

5.

Healthcare worker

❑

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Describe the impact of these potential traumatic experiences on you.

Understanding Workplace Realities

Occupation

Applies List the aspects of your to Me work that expose you to traumatic experiences.

6.

First responder during a disaster

❑

7.

Journalist

❑

8.

Transit or train operator

❑

Describe the impact of these potential traumatic experiences on you.

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Recovering from Workplace PTSD Workbook

Occupation

Applies List the aspects of your to Me work that expose you to traumatic experiences.

9.

Prison employee

❑

10.

Security guard/worker during an armed robbery

❑

11.

Prison employee

❑

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Describe the impact of these potential traumatic experiences on you.

Understanding Workplace Realities

Occupation

Applies List the aspects of your to Me work that expose you to traumatic experiences.

12.

Worker during an industrial site disaster

❑

13

Other

❑

Describe the impact of these potential traumatic experiences on you.

Notes

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Recovering from Workplace PTSD Workbook

Workplace Bullying, Harassment, and Discrimination Workplace bullying, harassment, and discrimination are tightly interrelated and when combined can make life at work very uncomfortable and traumatic. They can lead to PTSD if they are experienced consistently and persistently over time. Workplace bullying is a persistent pattern of mistreatment from others in the workplace that causes either physical or emotional harm. Bullying tactics include different types of abuse (verbal, nonverbal, psychological, and physical) and humiliation. There are several mental and physical health effects associated with bullying (Nielsen, Tangen, Idsoe, Matthieson, & Magerøy et al., 2015):

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Anxiety and depression

•

Sleeping problems

•

Fatigue or general restlessness

•

Somatic complaints like muscle aches or bone pain

•

Gastrointestinal issues such as irritable bowel syndrome

Understanding Workplace Realities

or ulcers •

Lack of concentration at work

•

Cardiovascular effects and high blood pressure

Bullies at work often operate within the established rules and policies of the organization and society. In most cases, they have authority over their victims, but they can also be peers and occasionally subordinates. Bullying can be covert or overt. Superiors can often miss it, even though it may be known by many throughout the organization. Adverse effects are not limited to the targeted individuals and may lead to a decline in employee morale and a change in organizational culture. It can take place as overbearing supervision, constant criticism, and blocking promotions. Harassment and discrimination are the two most common classes of intimidation applied to victims of bullying at work. Workplace harassment occurs when someone makes you feel humiliated, offended, or degraded in your place of employment. Other than workplace bullying, there are many other types of harassment that take place in the workplace. Being set up to fail is a well-established workplace bullying tactic (Peyton, 2004; Rayner & Hoel, 1997). It describes a nowin situation designed in such a way that the person in the scenario cannot succeed at the assigned task. For example, a project can be designed from the outset to fail by assigning insufficient resources and denying the team the necessary internal support to get the job done. Then, an internal “sham investigation” creates the impression that something is being done, but then the team is starved of the resources they need to 19

Recovering from Workplace PTSD Workbook

complete the investigation successfully. The inquiry will then conveniently fail to find any evidence of wrongdoing by the managers involved in setting up the investigation. In this situation, the bully is covertly sabotaging and undermining the victim’s ability to achieve success. This type of abuse can be the result of the bully projecting their feelings of inadequacy onto the victim. Intimidation is a form of harassment that involves some sort of veiled threat, typically job loss, to control and abuse targeted employees. There is often an underlying hidden economic agenda for bullying in the workplace. I recently spoke to a former colleague about her experience at work. When three people laid off in her department, she was given their duties. When I asked whether she received more compensation for her expanding responsibilities, she said no and that she was continually reprimanded for missing deadlines and not meeting goals. It made her wonder why she was never let go herself for supposed “poor performance.” Her manager simply referred back to those documented incidences of poor performance whenever she requested more compensation for her growing list of responsibilities. Cyberbullying is bullying that takes place using any sort of digital device and digital communication channels such as text, mobile apps, social media, and online forums. The anonymity of cyberbullying makes it difficult to know where the attack is coming from. Some cyberbullying crosses the line into criminal behavior. Cyberbullies share humiliating information about their victims through digital communication channels such as email, text 20

Understanding Workplace Realities

message, and chat. Cyberbullying includes posting or sharing negative, harmful, false, or abusive content about the victim on social media. A victim may experience racial harassment because of their race, skin color, ancestry, country of origin, or citizenship. Even perceived attributes of a particular ethnicity, such as curly hair, accents, customs, beliefs, or clothing, may be the cause. The following are signs of racial harassment: •

Racial slurs, insults, or jokes

•

Degrading comments

•

Disgust

•

Intolerance of differences

Gender harassment is a discriminatory behavior toward a person based on their gender. Gender stereotypes are at the heart of gender-based harassment. The following are examples of gender harassment: •

A male nurse faces harassment for having a perceived “woman’s job.”

•

A female banker hits the glass ceiling and is told she’s not “leadership material.”

•

A male employee displays images in his work space that are degrading to women.

Religious harassment centers on a victim’s religious beliefs. Religious harassment and racial harassment often occur together and are closely related. An individual with a religion that differs from the organization’s “norms” may face workplace 21

Recovering from Workplace PTSD Workbook

harassment or intolerance in a variety of ways: •

Intolerance toward religious holidays, traditions, and customs

•

Cruel religious jokes

•

Degrading stereotypical comments

•

Pressure to convert religions

Disability harassment can be directed toward individuals if they have a disability themselves, are acquainted with a disabled person or people, or use disability services such as sick leave or workers’ compensation. A person with a disability may experience these kinds of harassment: •

Harmful teasing and patronizing comments about disabilities

•

Refusal to reasonably accommodate an individual’s disability

•

Social isolation and stigmatization

Sexual orientation harassment has recently become recognized as a legitimate type of workplace harassment. Victims face harassment because their sexual orientation is different from those around them. People of any sexual orientation (heterosexual, gay, bisexual, asexual) can experience this form of harassment:

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•

A gay man faces harassment on a construction site.

•

A heterosexual man is teased for working in a hair salon.

•

A colleague greets a gay male worker with the feminine

Understanding Workplace Realities

version of his name, although he has asked them to use his proper name. •

A bisexual man is told by a coworker that he must be confused about his sexual identity.

Workers over age forty have age-related legal protections in many countries. These protections are an attempt to encourage the employment of older people and reduce age-based harassment (ageism), which is sometimes an attempt to push an individual to quit or enter early retirement. A person facing age-based harassment may experience •

Age-related teasing, insults, criticism, or stereotyping;

•

Being left out of activities or meetings by younger workers; and

•

Being informed they’re slated for retirement because they are the oldest employee in the company.

Personal harassment is workplace harassment that’s not based on race, gender, or religion. Private harassment is workplace bullying that creates an intimidating and offensive work environment for the victim. These are typical examples of personal harassment: •

Inappropriate comments

•

Offensive jokes

•

Acts designed to ostracize or humiliate

•

Critical remarks

•

Intimidation tactics 23

Recovering from Workplace PTSD Workbook

Physical harassment, often called workplace violence, involves physical attacks or threats. In extreme cases, physical harassment is simply assault. Physical gestures such as playful shoving are a gray area since it’s the person on the receiving end who decides whether the behavior makes them uncomfortable. Workers in healthcare, law enforcement, social services, education, retail, and public transit are at higher risk of workplace violence. Common physical harassment behaviors include •

Direct threats of intent to inflict harm;

•

Physical attacks such as hitting, shoving, or kicking;

•

Threatening gestures such as angrily shaking a fist; and

•

Destroying property to intimidate.

Power harassment can occur when there is a power disparity between the harasser and the harassed. The harasser exercises their power by bullying a victim in a subordinate position. Power harassment can take the form of verbal intimidation, sexual violence, aggressive physical contact, and threats of violence. The most common types of power harassment are psychological. Other power harassment scenarios include

24

•

Demanding unreasonable goals that are impossible to meet;

•

Making demeaning demands far below the employee’s capability; and

•

Intruding into an employee’s personal life.

Understanding Workplace Realities

Psychological harassment, which damages a victim’s mental well-being, can create a cascade that impacts their physical health, social life, and work life. Psychological harassment in the workplace can take a few forms: •

Opposing or challenging everything the victim says

•

Belittling or trivializing the victim’s thoughts

•

Discrediting or spreading rumors about the victim

•

Isolating or denying the victim’s presence

Sexual harassment refers to any unwanted sexual advances, conduct, or behavior. The following are examples of sexual harassment: •

Sharing or posting sexual photos or pornography in the workplace

•

Sexual comments, jokes, or questions

•

Inappropriate sexual touching or gestures

•

Invading someone’s personal space in a sexual way

Sexual assault is the act of intentionally sexually touching another person without that person’s consent or coercing or physically forcing a person to engage in a sexual act against their will. Sexual assault is a form of sexual violence, which includes rape, groping, sexual abuse, or the torture of the person in a sexual manner (Resnick, Acierno, & Kilpatrick, 1997). Quid pro quo sexual harassment is a type of exchange-based sexual harassment that can be either explicit or implicit. The harasser may outright ask for the exchange or just hint at it 25

Recovering from Workplace PTSD Workbook

(“Don’t you want this job?”). If a Power Abuser receives romantic or sexual services from the victim in exchange for receiving a job offer, promotion, or raise or avoiding a demotion or termination, that’s a form of blackmail. Third party harassment is workplace harassment that’s perpetrated by someone outside the organization. Instead of the perpetrator being a boss, supervisor, or colleague, the Power Abuser is a vendor, supplier, customer, or client of the organization. Victims are typically young adults in jobs with low status or low power. Their position in the company, lack of experience, and reluctance to report the harassment makes them ideal victims. Unfortunately, third party harassment often remains under-recognized and under-reported. Verbal harassment can result from personality conflicts that have escalated at work. Verbal abuse is often not illegal. It includes threatening, yelling at, insulting, or swearing at a victim in public or private. Long-term exposure to verbal harassment is particularly damaging because it can have a cumulative negative impact on the victim. It’s common for people on the receiving end of verbal abuse to experience feelings of shame and guilt, loss of passions, and even increased blood pressure. All workers should be protected against harm in the workplace—including harassment and violence. Unfortunately, this is not always the case. When harassment is left unaddressed, it can create a toxic work environment that’s hostile and unwelcoming. Your employer has a duty to ensure a workplace free from discrimination and harassment, which includes taking measures to prevent and ameliorate a toxic work environment. Everyone is entitled to a work environment 26

Understanding Workplace Realities

where everyone feels safe and is able to thrive professionally and personally. Workplace discrimination is closely related to workplace harassment and occurs when an individual is discriminated against for any number of factors. Discrimination based on race, religion, gender, or national origin when hiring or in the workplace is illegal in many regions of the world. It’s important to note that discriminatory practices can occur in any aspect of employment. Just as it is illegal for an employer to make assumptions based on race, gender, or age-related stereotypes, it is unlawful for an employer to assume that an employee may be incapable because they’re disabled. Direct discrimination occurs when you’re openly and directly treated poorly compared to another person in a similar situation because of a specific characteristic. Indirect discrimination is more subtle and occurs when an organization has a particular policy or way of working that applies to everyone but puts a specific class of people at a disadvantage. Indirect discrimination can be permitted if the organization or employer can show that there is a good reason for the policy. This rationale is known as objective justification. A hostile work environment is created when harassment or discrimination interferes with an employee’s work performance or creates a challenging or offensive work environment for an employee or group of employees. Age discrimination is a practice specially protected by law. With a few rare exceptions, organizations cannot specify an age preference in job advertisements. Employees must receive the 27

Recovering from Workplace PTSD Workbook

same benefits regardless of age, the only exception being when the cost of providing supplemental benefits to younger workers is the same as providing reduced benefits to older workers. It is illegal for employers to practice religious discrimination based on an individual’s religious customs. Businesses are required to reasonably accommodate an employee’s religious beliefs, as long as doing so doesn’t have excessively negative consequences for the employer. Gender discrimination occurs when female workers with the same qualifications, responsibility, skill level, and position are paid a lower salary than male workers. Employers are forbidden to discriminate based on gender. Businesses cannot lower one gender’s salary to equalize pay. Pregnancy-based discrimination is illegal. Employers are required to handle pregnancy in the same way that they would handle a temporary illness or other non-permanent condition that necessitates special consideration. Discrimination and harassment are structured into the social fabric through the process of inequality. Inequality is a silent force that warps reality, distorts what’s real, blames the victim, and is based in fear. Inequality is a social mechanism of power and control that can manifest in violent and destructive ways. Systems of inequality blame those who are suffering most. Giving one class of people less pay and fewer opportunities and rights than another class of people creates inequality. Inequality is justified and perpetuated by more powerful groups because maintaining it gives them an advantage. There are many types of inequality at play in the workplace. 28

Understanding Workplace Realities

Gender inequality acknowledges that men and women are not equal, and that gender affects an individual’s lived experience. These differences arise from distinctions in biology, psychology, and cultural norms. Some of these distinctions are empirically grounded, while others appear to be socially constructed. Studies show the different lived experiences of genders across many domains, including education, life expectancy, personality, interests, family life, careers, and political affiliations. Gender inequality is experienced differently across cultures. Racial inequality is an imbalance in the distribution of power, economic resources, and opportunities. Racial disparities are manifest through racial differences in wealth, poverty rates, housing patterns, educational opportunities, unemployment rates, and incarceration rates. Social inequality is the existence of unequal opportunities and rewards for different social positions or statuses within a group or society. Although the United States differs from most European nations with a titled nobility, the U.S. is still highly stratified. Social inequality has several dimensions. Income is a person’s earnings from work or investments, while wealth is the total value of their money and other assets minus debts. Further aspects include power, occupational prestige, schooling, ancestry, and race and ethnicity. Norms of allocation can affect the distribution of rights and privileges, social power, access to public goods such as education or the judicial system, adequate housing, transportation, credit and financial services such as banking, and other social products and services. Sexual orientation is another significant source of social 29

Recovering from Workplace PTSD Workbook

inequality. The bullying, violence, and other mistreatment experienced by the LGBT community have created significant educational and mental health effects. The most severe consequences are suicide, depression, anxiety, and trauma. Income inequality and poverty are the scarcity of material possessions or money. Poverty is a multifaceted concept, which may include social, economic, and political elements. Absolute poverty, extreme poverty, or destitution refers to the complete lack of the means necessary to meet basic personal needs such as food, clothing, and shelter. The threshold at which absolute poverty is defined is considered to be about the same, independent of the person’s permanent location or era. On the other hand, relative poverty occurs when a person who lives in a given country does not enjoy certain minimum living standards as compared to the rest of the country’s population. Therefore, the threshold at which relative poverty is defined varies from that country or society to another. Individuals with disabilities experience lower education levels, lower employment rates, fewer household resources, and poorer health than people without disabilities. Educational inequality is the unequal distribution of academic resources, including but not limited to school funding, qualified and experienced teachers, books, and technological resources, to socially excluded communities, which tend to be historically disadvantaged and oppressed. More times than not, individuals belonging to these marginalized groups are denied access to the schools with abundant resources. Inequality leads to significant differences in the educational success or efficiency of these individuals and ultimately suppresses their social and economic 30

Understanding Workplace Realities

mobility. There is no question that workplace bullying, harassment, and discrimination can all become sources of workplace trauma. When a person is repeatedly bullied, discriminated against, or harassed, they experience continued negative reinforcement, systematic abuse of power, and ongoing intimidation and emotional pain. Feelings of powerlessness, helplessness, anger, and fear develop. These feelings are strongly correlated with PTSD and making it more likely that a person who was bullied, discriminated, or harassed will develop PTSD (Nielsen et al., 2015). The trauma of bullying, discrimination, and harassment are typically cyclical or chronic for the person on the receiving end. Victims with less powerful occupational positions, limited higher education, and lower household incomes experience more workplace harassment. Employees with higher levels of authority, education, and income experience workplace harassment to a lesser degree (Islamoska, Grynderup, NabeNielsen, Høgh, & Hansen et al., 2018) One study examining mental health in college students found that experiencing bullying to be the strongest predictor of developing PTSD symptoms. This surpassed physical abuse, neglect, and exposure to community violence (Espelage, Hong, & Mebane, 2016). A research literature review by Stopbullying.gov (2017) examined 29 relevant studies on bullying and harassment and found that 57 percent of victims scored above the threshold for meeting PTSD criteria.

31

Recovering from Workplace PTSD Workbook

Workbook Exercise 1-2: Taking inventory of my workplace realities Goal The objective of this exercise is to identify which workplace realities are impacting you today or have affected you in the past. Instructions Below is a list of workplace realities: 1. Identify if the workplace reality is impacting you in the present or did in the past. 2. Describe how you experience relevant workplace realities. 3. Describe how the relevant workplace realities are impacting you. Type

Corporate Realities

Power

Office politics are harming me.

32

Now Past Describe how you experience the workplace reality, if relevant.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

Understanding Workplace Realities

Type

Workplace abuse

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

Corporate culture has a mantra: “Don’t take it personally; it’s just business.”

❑

❑

Someone is abusing power, and it is having a detrimental effect on me.

❑

❑

I work in a hierarchical organization with more influential people above me.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

33

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Type

34

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

Someone is using power to abuse me at work.

❑

❑

I’m being bullied at work.

❑

❑

I’m being harassed at work.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

Understanding Workplace Realities

Type

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

I’m being discriminated against at work.

❑

❑

Questionable Unethical behaviors are Ethics and happening at work. Fraud

❑

❑

❑

❑

I have directly witnessed unethical acts at work.

Describe the impacts of the workplace realities on you, if relevant.

35

Recovering from Workplace PTSD Workbook

Type

Toxic Workplace

36

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

I’m being asked to do things at work that contradict my morals and personal ethics.

❑

❑

There are significant communication issues, infighting, and personal employee battles that harm productivity at work.

❑

❑

Workplace bullying, harassment, and violence are also prevalent at work.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

Understanding Workplace Realities

Type

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

Dangerous Working Conditions

I have a job that exposes me to traumatic experiences occasionally.

❑

❑

I have a job that exposes me to violence.

❑

❑

I have a job that exposes me to threats to my health.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

37

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Type

Persistent Workplace Trauma

38

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

I have a job that exposes me to threats because it involves responding to emergency situations.

❑

❑

I often work long hours and excessive overtime.

❑

❑

I’m regularly stressed at work.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

Understanding Workplace Realities

Type

Corporate Realities

Now Past Describe how you experience the workplace reality, if relevant.

I’m expected to be reachable by a supervisor after work hours.

❑

❑

I’m forbidden to take time off work for family emergencies or to recover from stress.

❑

❑

My work environment is inflexible toward my personal needs.

❑

❑

Describe the impacts of the workplace realities on you, if relevant.

39

Recovering from Workplace PTSD Workbook

Notes

Power Abusers Are in Positions of Authority Corporate power dynamics are behind all work relationships to some degree. But when power is abused, it creates opportunities for more powerful individuals to traumatize those who have less. Power becomes abusive when it crosses the line into manipulative and coercive behavior. Abusive power, control, or coercion are ways an abusive person gains and maintains power and control over another person so they can subject their target to psychological, physical, sexual, or financial abuse. Keep in mind that the power structure you’re working in today may be very different next year. Shifting power dynamics typically occur during reorganizations, when hiring new 40

Understanding Workplace Realities

managers, during layoffs, and after senior leadership shuffles. These organizational changes have significant impacts on our daily work life. A Power Abuser is an individual who uses their power in abusive and coercive ways to control another person, their victim. The Power Abuser’s motivations include devaluation, envy, personal gain, personal gratification, or psychological projection. Power Abusers wield their power for the following reasons: •

They feel powerless, despite their worldly successes.

•

They are bullies.

•

They enjoy the feeling of exercising power and control.

•

They seek personal gain and personal gratification.

•

They are envious and jealous of other people.

•

They express their anger in violent and abusive ways.

•

They receive sadistic pleasure from seeing others suffering and in pain.

Let’s discuss now why managers abuse subordinates. First, the corporate power structure creates social norms that pressure managers to exert power and control to gain respect from more senior managers. Second, managers abuse subordinates because they have accumulated past psychological and emotional injuries and shame that they can now safely offload onto a subordinate in a socially acceptable way. Supervisors can offload two sources of shame onto their subordinates. The first is depriving shame, which accumulates 41

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when the abusive manager was not supported or validated as a child. Over time deprived shame transforms into feelings of worthlessness. The second is punishing shame, which forms when an abusive manager experienced severe childhood reprimands. When these individuals become managers, they have a propensity to become highly abusive toward their employees. Shame and self-worth issues play an important role in why someone wants to become a manager in the first place. Their need to gain social status and power drives them to strive for positions of superiority and self-entitlement. Forms of Physical Abuse Physical abuse is an act where one person uses their body in order to inflict intentional harm or injury upon another person. This form of abuse can lead to serious consequences for the victim in the moments following the physical abuse and for their entire lifetime. Physical abuse can involve someone slapping another person. Another form of physical abuse involves brushing someone aside or hair pulling. Don’t assume physical abuse always has to involve direct contact. Some forms of physical abuse are indirect. For example, someone may spit at you and even if they didn't directly hit you, it is still a physically abusive act. Worse, an individual may throw an object at you, like a chair. Direct body-to-body contact didn't occur, but this act is highly physically aggressive. Other, more obvious forms of physical abuse include:

42

• • •

Punching, Kicking Shaking Suffocating

• • •

Pinching Biting Scratching

Understanding Workplace Realities •

Scalding or burning someone

Power Abusers use a variety of tactics to exert power and control over their targeted victims. These tactics are psychological and sometimes physical. Power Abusers selectively target individuals they recognize as being particularly vulnerable then use those vulnerabilities to systematically control and abuse them. Often the Power Abuser attempts to normalize, legitimize, rationalize, deny, or minimize their abusive behavior. It is also common for the Power Abuser to blame the victim for their vulnerabilities to further erode their self-esteem. Traumatic bonding can form between the Power Abuser and the victim when abuse continues over a more extended period. Repeated cycles of reward and punishment create powerful emotional bonds that are resistant to change and lock the victim into a climate of fear. There are several telltale signs that you’re becoming the target of coercive control. If you detect any of these tactics being used on you, it is highly likely that you’re the target of a campaign of abusive power. I’ll review the most frequently used tactics in the power abuser’s toolbox. The Power Abuser Toolbox of Tactics • • •

Lying, disinformation, and propaganda Isolation Destabilization

• •

Divide and rule Playing hard to get 43

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• • •

Projection Sending mixed messages Guilt tripping

• • •

Withholding validation or positive feedback Love bombing Testing limits

•

Gaslighting Scapegoating

•

Lying, disinformation, and propaganda are tactics that create a reality distortion field around the victim to control and remove their power. Power Abusers use a campaign of propaganda and misinformation to persuade large numbers of people about the truth of their perspective. Propaganda presents one side of an argument as patently true regardless of whether it is or not. False beliefs can be more easily implanted in people when their brain functioning has been disturbed by fear, anger, or excitement. The user of propaganda will lie, cheat, deceive, and blatantly disregard the rules of honest debate. A dynamic of “us versus them” is set up using the excuse that “the ends justify the means.” Propaganda, lying, and disinformation techniques applied by a workplace Power Abuser include

44

•

Spreading false rumors, particularly ones that are damaging to your professional reputation and competence;

•

Creating the impression of poor work performance by sharing misleading information or lies; and

•

Spreading disinformation about alleged errors, mistakes, theft, or fraud.

Understanding Workplace Realities

Isolation is used to weaken the victim by preventing them from hearing other people’s perspectives. Power Abusers can further isolate them by •

Removing your areas of responsibility;

•

Controlling incoming information;

•

Gossiping about you; and

•

Subjecting you to social ridicule.

Destabilization is a brainwashing technique used to disorient and disarm the victim. The most common destabilization techniques at work are •

Failing to acknowledge your excellent work;

•

Not valuing your effort;

•

Assigning you meaningless tasks;

•

Removing areas of responsibility without consulting you;

•

Repeatedly reminding you of blunders;

•

Intentionally setting you up to fail;

•

Changing goals without telling you; and

•

Attempting to demoralize you.

Divide and rule is a tactic to gain and maintain power by breaking up concentrations of power into smaller pieces with less power. Examples of this tactic at work include •

Breaking up teams of which you’re a member into smaller groups with less power and influence than the larger group;

•

Assigning many small projects to you, each with less 45

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corporate impact; •

Removing you from strategic activities to erode your power and influence; and

•

Transferring you to independent tasks and away from group activities.

Playing hard to get creates the perception of being more valuable in the eyes of others by manufacturing a busy and indemand aura. This tactic fabricates an illusion that the victim is chasing the Power Abuser. Techniques for manufacturing this carefully crafted reality distortion at work are •

Being out of the office and difficult to contact;

•

Having limited availability and always seeming busy;

•

Taking a long time to respond to calls and emails or not responding at all;

•

Vague communication that is designed to create a sense of mystery and importance;

•

Scheduling meetings and events after a time delay;

•

Prioritizing you lower on their list of priorities;

•

Seeking attention but then disregarding it; and

•

Acting confident, limiting self-disclosure, and not expressing many emotions.

Projection takes place when the Power Abuser attributes their thoughts and actions to the victim. For example, the abuser may blame the victim for being incompetent and unable to do their job effectively. In reality, the abuser is incompetent at their job and doesn’t want that reality to be noticed or uncovered. When victims are forced to expend energy defending themselves, 46

Understanding Workplace Realities

they’re distracted from evaluating the actions of their abuser. Other examples of projection at work are •

Defining you with attributes or characteristics that don’t fit who you are and what you know about yourself;

•

Making you expend energy defending yourself from ongoing personal attacks that don’t feel justified or relevant;

•

Trying to talk through a concern they raised earlier and being told you shouldn’t worry;

•

Getting upset and calling them out on their abusive behavior, but then being blamed for overreacting;

•

Giving you the silent treatment for no apparent reason and then blaming you for a minor incident that happened in the past; and

•

Manufacturing a problem, refusing to discuss it, and blaming you for it.

A person who sends mixed messages will act interested, ignore you completely, and then appear interested again later. The purpose of this behavior is to make you feel desperate, insecure, and focused on them. Mixed signals make us think we’re crazy; we wonder if we’re valued and become concerned our job is at risk. Feeling like you have no idea what’s going on triggers completely understandable insecurities and anxieties. A few signs you’re receiving mixed messages are •

A lack of response from the abuser to your communication, a lack of general interest in you, or the impression that they’re dealing with more pressing concerns; 47

Recovering from Workplace PTSD Workbook

•

Unfriendly behavior directed toward you, or the abuser is awkward or uncomfortable in your presence;

•

No desire to discuss issues important to you and a lack of caring when you raise them; and

•

Sending messages that they no longer value you.

Guilt tripping is a passive-aggressive psychological manipulation designed to illicit unjustified feelings of guilt or responsibility from the victim. The victim is blamed for an artificially manufactured transgression to make them feel guilty. The victim’s guilt is used to coerce them into doing something they would not ordinarily do, but the Power Abuser wants them to do. Examples of workplace guilt trips are •

Pressure applied to make you volunteer for unpaid overtime; and

•

Reminders of how you’ve been helped in the past, which is used to justify requiring you to take on additional responsibilities you don’t have time for.

Withholding validation or positive feedback often happens in our work relationships. Coworkers withhold positive feedback and praise if they don’t get what they want. Everyone has a desire to be liked and appreciated, and that is why withholding validation and positive feedback is such a powerful tactic—it is the absence of caring, compassion, communication, and connection. This tactic plays on our deepest fears of rejection, unworthiness, shame, and guilt. Our instinct is to worry that we’ve done something wrong, feel like we’ve failed, and reach the conclusion that something is wrong with us. Some examples of this tactic at work are 48

Understanding Workplace Realities

•

You delivered results beyond expectations, and those efforts are not attributed to you;

•

There is a complete absence of positive feedback for your efforts and successes.

Love bombing is a tactic manipulative people use in the initial stages of getting to know someone new. They shower you with praise, buy you gifts, or nominate you for recognition awards. Love bombing will usually feel too intense and inappropriate for that stage of the relationship. These scenarios are examples of love bombing at work: •

A new colleague or manager gives you a surprise welcome gift when they join the organization.

•

A new manager who doesn’t know your work well nominates you for a recognition award.

•

During your initial meetings with a new colleague or manager, you’re showered with praise and admiration that feels uncomfortable and inappropriate.

Testing limits occurs when a person intentionally does something hurtful or disrespectful to test your reactions and boundaries. The goal of limit testing is to check if you’ll stand up for yourself and identify if you have weak boundaries. Power Abusers scan their environment for anyone with weak personal boundaries and zero in on those individuals. If you experience signs of limit and boundary testing, you should proceed with extreme caution and defend your personal boundaries. It can be challenging to identify when your limits are being tested; these are some warning signs: 49

Recovering from Workplace PTSD Workbook

•

You blame yourself for things going wrong.

•

You feel shame.

•

You start doubting your decisions.

•

You sense something is wrong and cannot pinpoint what it is.

•

Your intuition is telling you there may be a hidden agenda.

•

Your decisions are disregarded.

If you’re concerned it’s happening, try incorporating these phrases into your communication. If you receive pushback and strong defensive reactions, it’s highly likely your limits are being tested.

50

•

No.

•

Stop.

•

I’m drawing new lines around that and need you to respect them.

•

I’m uncomfortable with this.

•

I’m no longer willing to do that.

•

That doesn’t work for me.

•

Things need to change because this isn’t working for me.

•

I’m upset by what just happened.

•

Let me explain my perspective on what you did.

•

I’m afraid I have to disagree.

•

You’re asking me to put myself in danger, and I won’t do it.

•

I’m not following you; please say that differently.

Understanding Workplace Realities

Gaslighting is psychological manipulation that seeks to sow seeds of doubt in a targeted individual or members of a targeted group. This strategy is designed to force the target to question their memory, perception, and sanity. Persistent denial, misdirection, contradiction, and lying are intended to destabilize the victim’s beliefs. The gaslighter, usually a witty or charming person, is often trying to get someone fired or into trouble at work. It can be challenging to pinpoint precise examples of gaslighting. Focus on situations and relationships where a coworker or boss first told you one thing and then later told you they said something completely different. Consider these examples: •

Your manager told you the project was due next week, but today threatens to fire you because you haven’t completed it yet.

•

Your coworker tells you they heard your boss speaking badly about you, but when you ask about what was said, your boss tells you they didn’t say anything negative.

•

A coworker makes racist, sexist, or derogatory comments and later acts as if they didn’t.

•

You notice that you’re being excluded from essential email threads “by accident” and then told you’re overreacting to the situation.

•

A manager or coworker takes credit for an idea you presented. They inform you the idea had to be improved and make you question if it’s still your idea.

Gaslighting is challenging to detect, so stay alert for some of 51

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these warning signs from abusers: •

They listen long enough to collect information from you but are not fully engaged in the listening process. They don’t show signs of authentically caring about what you’re saying.

•

They lie and manipulate you into thinking it was you who made them lie in the first place.

•

They show low to zero accountability.

•

They gather information, twist it to their advantage, and use it against you or others later.

•

They gossip because it gives them ammunition to discredit you or others later.

•

They appear confident; however, if you observe them more closely, they are really insecure people with an inability to self-regulate their emotions and thoughts.

•

They consistently leave you feeling inadequate.

Here are a few practical things you can do when you notice signs of gaslighting at work:

52

•

Place boundaries early if you see warning signs.

•

Try to limit your communication to written formats, so you have a record to refer to later.

•

Think through what respect looks like for you. If you observe a lack of respect from an individual, you’re vulnerable to gaslighting.

•

Reaffirm your self-worth and take inventory of all the things you’re good at.

Understanding Workplace Realities

•

Combat lingering doubts about your skills that someone might be trying to instill in you.

Scapegoating is the practice of singling out a person or group for underserved blame to justify adverse treatment. Here are a few examples: •

Individuals against individuals — “He did it, not me!”

•

Individuals against groups — “I couldn’t hear anything because of all the people talking loudly.”

•

Groups against individuals — “Michael was the reason our team missed the project deadline.”

•

Groups against groups — “The managers weren’t able to exceed their quarterly sales targets because the sales reps called in sick too often.”

•

A crafty manager who’s prone to scapegoating will deflect responsibility when things go wrong or make excuses for their weaknesses by blaming others.

In chronic scapegoating, one person is chosen for abuse by a group. Everyone joins in as a way to vent negative feelings that can’t otherwise be addressed in the toxic work environment. The scapegoat receives the adverse treatment because their behaviors don’t match group norms, and they become isolated and singled out. If the scapegoat leaves the company, another employee will typically replace the original scapegoat. Whether verbal, psychological, or even physical, abuse in any form is traumatic for the victim. Many employees feel understandably powerless working in a corporate environment with a rigid power structure. The organizational power 53

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structures are taken advantage of by Power Abusers to control and victimize their subordinates. Those abusers systematically target vulnerable people with weak boundaries by first identifying them, testing boundaries, and using power tactics to control them. Trauma robs survivors of their sense of control and leaves them vulnerable to revictimization. Regaining a sense of power and control is the first thing we need to do in the aftermath of trauma. Survivors are often obsessed about safety and having authority in their lives and will attempt to regain power and control by any means necessary. Power Abusers are skilled at being able to read vulnerability, and PTSD survivors become an easy target. Moreover, when power tactics are applied repeatedly to an individual at work, the cumulative effect can be the development of PTSD. Neglectful or ongoing abuse occurs when employees’ basic needs are not met, or they are blamed for expressing these needs.

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Workbook Exercise 1-3: Identifying my Power Abuser and the control tactics Goal This exercise will help you work through the different tactics your Power Abuser uses to exert power and control over you. Definitions •

Power Abuser: The individual using their power and control to manipulate you.

•

Power Objective: The particular power objective the Power Abuser is seeking to achieve.

•

Power Tactic: A particular tactical approach used to achieve a specific power objective.

Instructions •

Below are the most common tactics Power Abusers use on their victims.

•

Review each power tactic and decide which of them are relevant to your situation.

•

If one is relevant, describe how your Power Abuser uses the tactic to exert power over you, abuse you, traumatize you, or control you.

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Power Objective

Power Tactic

Lying, disinformation, and propaganda

Spreading false rumors, particularly ones damaging to your professional reputation and competence

❑

Creating the impression of poor work performance by sharing misleading information or lies

❑

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Relevant

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Isolation

Power Tactic

Relevant

Disinformation about alleged errors, mistakes, theft, or fraud

❑

Other

❑

Removing areas of responsibility

❑

Describe how this power tactic is being used on you.

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Power Objective

58

Power Tactic

Relevant

Controlling incoming information

❑

Gossip and social ridicule

❑

Other

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

Destabilization

Failure to acknowledge good work

❑

Failure to value the victim’s efforts

❑

Assigning meaningless tasks

❑

Describe how this power tactic is being used on you.

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Power Objective

60

Power Tactic

Relevant

Removing areas of responsibility without consultation

❑

Repeated reminders of blunders

❑

Setting the victim up to fail

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

Changing goals without notice

❑

Persistent attempts to demoralize the victim

❑

Other

❑

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

Playing hard to get

Being out of the office or not easily accessible

❑

Having limited availability

❑

Taking a long time to respond to calls and emails or not responding at all

❑

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Relevant

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

Vague communication designed to create a sense of mystery and importance

❑

Schedule meetings and events after a time delay

❑

Prioritizing other things

❑

Describe how this power tactic is being used on you.

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Power Objective

64

Power Tactic

Relevant

Being difficult to get a hold of

❑

Seeking attention but then disregarding it

❑

Acting confidently, limiting selfdisclosure, and not expressing many emotions

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Divide and rule

Power Tactic

Relevant

Other

❑

I’m experiencing lying, disinformation, and propaganda.

❑

An individual or individuals are isolating me from others.

❑

Describe how this power tactic is being used on you.

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Power Objective

Projection

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Power Tactic

Relevant

I’m experiencing feelings of being kept “off-balance,” and this makes me feel unstable at work.

❑

Other

❑

You are blamed for being incompetent, and there is clear evidence that the Power Abuser is incompetent.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

You are defined by attributes or characteristics that don’t fit with who you are and what you know about yourself.

❑

You are expending much energy defending yourself from ongoing personal attacks that don't feel justified or relevant.

❑

When you get upset and call them out on their abusive behavior, they blame you for overreacting.

❑

Describe how this power tactic is being used on you.

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Power Objective

68

Power Tactic

Relevant

You are given the silent treatment for no apparent reason and then blamed for a minor incident that happened in the past.

❑

They manufacture a problem, refuse to discuss it, and blame you for it.

❑

You talk through a concern they raised earlier and are told there is nothing to worry about.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Sending mixed messages

Power Tactic

Relevant

Other

❑

They don’t respond to your communication, appear to be generally disinterested in you, or give the impression they’re dealing with more pressing concerns.

❑

They act in an unfriendly way toward you or seem awkward or uncomfortable in your presence.

❑

Describe how this power tactic is being used on you.

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Power Objective

Guilt tripping

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Power Tactic

Relevant

They don’t want to discuss issues that are important to you when you raise them and appear not to care.

❑

Guilt and coercion are applied to pressure you into volunteering for unpaid overtime.

❑

You are reminded of how you’ve been helped in the past, and that’s used as a justification for requiring you to take on additional responsibilities you don’t have time for.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Withholding validation or positive feedback

Power Tactic

Relevant

Other

❑

You delivered results beyond expectations, and your efforts are not attributed to you.

❑

Your efforts and successes at work are ignored.

❑

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

There is a complete absence of positive feedback for your efforts and successes.

Relevant

❑

Other

Love bombing

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A new colleague or manager gives you a surprise welcome gift when they join the organization.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

A new manager who doesn't know your work well nominates you for a recognition award at work.

❑

During your initial meetings with a new colleague or manager, you’re showered with praise and admiration that feels uncomfortable and inappropriate.

❑

Other

❑

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

Testing limits

You blame yourself for things going wrong.

❑

You feel shame.

❑

You start doubting your decisions.

❑

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Relevant

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

You sense something is wrong and cannot pinpoint what it is. Your intuition is telling you there may be a hidden agenda.

❑

Your decisions are disregarded.

❑

Other

❑

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

Gaslighting

They listen long enough to collect information from you but are not fully engaged in the listening process. They don’t show signs that they authentically care about what you’re saying.

❑

They lie and make you feel like it was your fault that they had to lie.

❑

They show low to zero accountability.

❑

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Relevant

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

They gather information, twist it to their advantage, and use it against you or others later.

❑

They gossip because it gives them ammunition to discredit someone later.

❑

They appear confident; however, if you observe them more closely, they are insecure and unable to selfregulate their emotions and thoughts.

❑

Describe how this power tactic is being used on you.

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Power Objective

Being set up to fail

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Power Tactic

Relevant

They consistently leave you feeling that you’re inadequate.

❑

Other

❑

You’ve been put in a manufactured situation designed so that you cannot succeed at an assigned task.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

Information necessary to succeed at a task you’ve been given is deliberately withheld to derail your success.

❑

Resources necessary to succeed at a task you've been given are deliberately withheld or removed to sabotage your success.

❑

Other

❑

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

Scapegoating

A crafty manager is never blamed when things go wrong at the workplace. It’s always the fault of others.

❑

Managers make excuses for their weaknesses and make scapegoats out of their employees.

❑

Other

❑

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Relevant

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

Relevant

Intimidation

You are being threatened with a layoff, demotion, or termination in a non-empathetic and confrontational way.

❑

Without warning, you are presented with a performance improvement plan (PIP) structured in such a way that you cannot possibly succeed.

❑

During meetings with a particular individual, you are physically threatened.

❑

Describe how this power tactic is being used on you.

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Power Objective

82

Power Tactic

Relevant

Your personal space has been deliberately invaded, and you felt threatened by the experience.

❑

You have experienced intimidating body language that has left you feeling threatened and shaken.

❑

You’ve been physically assaulted.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Workplace Bullying

Power Tactic

Relevant

You’ve been sexually assaulted.

❑

Other

❑

A persistent pattern of mistreatment from others in the workplace has caused you either physical or emotional harm.

❑

Describe how this power tactic is being used on you.

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Power Objective

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Power Tactic

Relevant

I have experienced verbal abuse, nonverbal abuse, psychological abuse, physical abuse, or humiliation.

❑

Established workplace rules and policies are being applied to me in a cruel and manipulative way to hurt or intimidate me.

❑

An overbearing supervisor constantly criticizes me or blocks promotions.

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Cyberbullying

Power Tactic

Relevant

Other

❑

Sending, posting, or sharing negative, harmful, false, or abusive content online

❑

Sharing humiliating things about you by mass email or mass chat

❑

Describe how this power tactic is being used on you.

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Power Objective

86

Power Tactic

Relevant

Spreading lies or gossip about you on social media

❑

Sending harassing instant messages or text messages directly to you

❑

Other

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Power Tactic

Relevant

Harassment

Someone at work is making you feel humiliated, offended, or degraded.

❑

When you address the issue with the perpetrator, you’re told it was just a joke.

❑

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

You’re experiencing one or more of these types of harassment:

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•

Racial harassment

•

Gender harassment

•

Religious harassment

•

Disability harassment

•

Sexual orientation harassment

•

Age-based harassment (ageism)

•

Personal harassment

•

Physical harassment

•

Power harassment

•

Psychological harassment

•

Sexual harassment

•

Sexual assault

•

Third party harassment

•

Verbal harassment

Relevant

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Power Objective

Discrimination

Power Tactic

Relevant

Other

❑

You’re experiencing one or more of these types of discrimination:

❑

•

Direct discrimination, via extensive and immediate adverse treatment because of a specific characteristic

•

Indirect discrimination, via unfair workplace policies or rules

•

Hostile work environments

•

Age discrimination

•

Religious discrimination

•

Gender discrimination

•

Pregnancy-based discrimination

Describe how this power tactic is being used on you.

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Power Objective

Power Tactic

I’m being discriminated against based on my: •

Age

•

Gender

•

Race

•

Ethnicity

•

Skin color

•

National origin

•

Mental or physical disability

•

Genetic information

•

Relationship to someone who may be discriminated against

•

Pregnancy or parenthood

Other

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Relevant

❑

❑

Describe how this power tactic is being used on you.

Understanding Workplace Realities

Notes

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Toxic Workplaces Toxic environments, at their core, are ineffective and destructive to employees. When supervisors and coworkers routinely mistreat each other and act in self-serving ways without considering what’s best for the larger group’s success, the culture of the organization becomes dysfunctional and employees become cynical. Employees start to believe raises and promotions are given for political reasons to undeserving people, or managers only look out for their best interests so the employees feel they should do the same. Employees may feel that behaving ethically only puts them at a disadvantage compared to their coworkers, so their only option is to engage in the same unethical practices or leave the company. Characteristics of Toxic Workplaces • • • •

Cynicism Poor communication Never celebrate success Corruption and unethical behavior

• • • •

Lack of freedom and no trust Fear of adapting and changing All business, all the time Incompetent leadership

• • •

Failure to “walk the talk” Lack of positive organizational culture High employee turnover Stressed and sick employees

•

When a workplace becomes toxic, turnover increases and productivity declines. People who have experienced previous 92

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forms of trauma are more likely to have a negative emotional response to toxic workplaces. The National Institute for Occupational Safety and Health (NIOSH) (1999) identified toxic workplace environments as a leading cause of workplace violence. These environments exhibit verbal violence, such as threats, verbal abuse, hostility, and harassment. Verbal assaults and hostility frequently escalate into physical violence. These assaults lead to psychological trauma and stress, even when there is no bodily injury. Everyone is impacted negatively by working in a tense and stressful atmosphere. If supervisors become angry and verbally abusive with their employees, any positive rapport stops. Employees stop trying to communicate honestly and openly with their supervisors out of fear. Without clear and accurate information from their employees, supervisors no longer make the best decisions for the employees or the organization. Employees in toxic work environments often suffer from these physical and mental health complaints (International Labour Office, 2018): •

Cardiovascular disease: Many studies have found psychologically demanding jobs that give employees little control over the work process increase the risk of cardiovascular disease.

•

Musculoskeletal disorders: Research by NIOSH and many other organizations suggests that job stress increases the risk for the development of back and upper-extremity musculoskeletal disorders.

•

Psychological disorders: Studies suggest that rates of 93

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mental health problems (depression and burnout) vary by occupation and level of job stress. •

Workplace injury: Research has shown that stressful working conditions interfere with safe work practices and set the stage for injuries at work.

•

Stress-related health issues: Suicide, cancer, ulcers, and impaired immune function are common stressrelated health issues found in toxic work environments.

Nobody gets excited about anything in toxic workplaces. Acquiring a big client account, closing a big deal, or exceeding sales goals will never be celebrated. These organizations are laser-focused on the bottom line, and employee morale is wholly overlooked. A lack of trust and accountability in toxic environments can also cause employees witnessing corruption or unethical practices to look the other way and avoid speaking out. Toxic workplaces have been linked to corporate scandals and environmental disasters. Toxicity seeps into the workplace when employees focus on protecting themselves instead of doing the right thing for the organization or community. In their review of the literature on crisis and unethical behavior at work, Christensen and Kohls (2003) found that ethical crises at work lead to stress and negative consequences for everyone involved in the unethical practices. Ethical conflicts have a cumulative impact on those involved because ethical dilemmas challenge our belief systems, and that amount of increased stress eventually impacts our physical and emotional health. For 94

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example, journalists working on crisis-related assignments may experience ethical dilemmas linked to how they conduct their work without causing additional harm to the victims. Backholm and Idås (2015) investigated how exposure to journalistic ethical dilemmas during the Oslo and Utøya terror attacks in 2011, and subsequent work-related guilt, were related to the development of PTSD. The results showed that exposure to ethical dilemmas might affect the development of long-term negative psychological impacts. Those impacts are experienced by workers who witnessed unethical acts or were connected to the unethical behavior. These negative impacts are the result of empathy for the victim or perpetrator. Ethical dilemmas force people to consider the potential effects on their lives, and fears surface that cause anxiety, trauma, and in some cases PTSD (Promiski, Giacalone, & Jurkiewicz, 2016). There is mounting evidence that suggests employees who exercise autonomy regularly at work are happier and more productive. The right workers in the right role can transform an entire department—maybe even an entire organization—but only if their ability to act on their intuition and creativity is unleashed. Individuals can only make changes within an organization when they are given the freedom to do that. Freedom and trust go hand in hand. If managers don’t trust their teams to do a job, the job will likely never get done. If employees aren’t trusted to fulfill their roles, they will start losing confidence in the organization and productivity will decrease. Functional and competent leaders understand they cannot be involved in every decision. Instead, they hire the right 95

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people and empower them to make their own decisions. If they fail, they will learn and grow from their own mistakes. A toxic workplace, in comparison, does not invest in or listen to its employees and has no standards of excellence to strive for. In these settings, leaders have all the answers and fail to acknowledge accomplishments, outstanding performance, and milestones. It’s healthy to maintain separation between your professional and personal lives. Toxic work environments, however, don’t allow employees to maintain a healthy balance, requiring them to work overtime and respond to emails out of work hours. Organizational leaders are responsible for setting the tone of the culture and driving the corporate vision. That means if leaders work in a vacuum, without considering their employees, the environment rapidly becomes toxic. Toxic leadership silences anyone who challenges the status quo and creates “skilled incompetence” by asking employees to “do as I say, not as I do.” Toxic organizations also fail to “walk their talk” because the behaviors they profess to value are not supported. For example, an organization might claim publicly to welcome diversity and an entrepreneurial spirit and then discourage these behaviors by not supporting employees’ innovative ideas. Toxicity, in essence, is created in the gap between what is said and what is done. Cultural toxicity evolves when there is a lack of authentic and balanced communication throughout the organization. Employees are not empowered to contribute to the evolution of the work culture collaboratively. High employee turnover occurs in toxic work environments. 96

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People don’t want to stay in companies where stress levels are excessive, verbal abuse is common, hard work goes unrewarded, communication has broken down, and unethical behavior is typical. When employees don’t stay for long before moving on, the likely cause is a toxic work environment. Until the corporate culture changes, the situation will not improve. The American Psychological Association research (APA, 2013) found that 36 percent of workers report ongoing work stress, most of which was related to harmful or outright unhealthy management practices. Between 40 and 50 percent of respondents reported a heavy workload, long hours, abusive managers, and unrealistic expectations as reasons for their emotional distress. Nearly 50 percent reported not feeling valued on the job, and about one-third intended to look for another position within the next year. Job stress has become a familiar and costly problem (NIOSH, 1999): •

One-fourth of employees view their jobs as the number one stressor in their lives.

•

Three-quarters of employees believe workers have more on-the-job stress than they did a generation ago.

•

Problems at work are more strongly associated with health complaints than non-work life stressors like family and financial issues.

A toxic work environment can lead people to fall into a cycle of learned helplessness. When this happens, workers can’t think clearly and have difficulty figuring out effective ways to exit this harmful situation. 97

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Workbook Exercise 1-4: Am I experiencing a toxic workplace? Goal This exercise helps you think through if your current or former workplace shows signs of being toxic. Recalling examples will help you remember a previous toxic workplace situation and help you identify the impact it had on you. Instructions The indicators of a toxic workplace are listed below.

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•

Refer back to the information earlier in this section about toxic workplaces.

•

Identify the toxic workplace indicators that apply to your current or former workplace.

•

Share an example of when you noticed the toxic workplace indicator at work, if relevant.

•

Finally, briefly describe how the situation recalled in the example impacted you, if relevant.

Understanding Workplace Realities

Toxic Workplace Indicators

Relevant

1.

Cynicism

❑

2.

Poor communication

❑

3.

Never celebrate success

❑

Share an example of a situation where you noticed this toxic workplace indicator, if relevant.

Describe the impact the situation recalled in the example had on you, if relevant.

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Toxic Workplace Indicators

Relevant

4.

Corruption and unethical behavior

❑

5.

Lack of freedom and no trust

❑

6.

Fear of adapting and changing

❑

100

Share an example of a situation where you noticed this toxic workplace indicator, if relevant.

Describe the impact the situation recalled in the example had on you, if relevant.

Understanding Workplace Realities

Toxic Workplace Indicators

7.

All business, all the time

8.

Poor Leadership

9.

Failure to “walk the talk”

Relevant

Share an example of a situation where you noticed this toxic workplace indicator, if relevant.

Describe the impact the situation recalled in the example had on you, if relevant.

❑

❑

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Toxic Workplace Indicators

Relevant

10.

Toxic culture

❑

11.

High employee turnover

❑

12.

Stressed and sick employees

❑

102

Share an example of a situation where you noticed this toxic workplace indicator, if relevant.

Describe the impact the situation recalled in the example had on you, if relevant.

Understanding Workplace Realities

Toxic Workplace Indicators

13.

Relevant

Share an example of a situation where you noticed this toxic workplace indicator, if relevant.

Describe the impact the situation recalled in the example had on you, if relevant.

❑

Other

Notes

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Synopsis

104

•

Some careers have a higher risk of workers experiencing traumatic events that can lead to the development of PTSD.

•

Power dynamics are inescapable and omnipresent at work, and they create opportunities for individuals with the power to traumatize employees with less power.

•

The power dynamics between managers and subordinates can exploit many ingenious and underhanded ways to control and coerce others.

•

Abusive power, control, or coercion are ways an abusive person gains and maintains power and control over another person.

•

Workplace bullying, harassment, and discrimination make

Understanding Workplace Realities

life at work uncomfortable and traumatic. These experiences accumulate and eventually lead to PTSD symptoms. •

A toxic workplace has significant communication issues, infighting, and personal employee battles that harm productivity and are destructive to employees.

•

Complex PTSD (C-PTSD) develops when victims find themselves trapped in dangerous environments where they become traumatized and repeatedly revictimized.

•

Grieving workers, whether out of fear or embarrassment, often try to park their emotions at the door, hoping their fragility won’t be obvious to coworkers.

•

The workplace can struggle with the dichotomy between helping people grieve and maintaining productivity.

•

Coworkers often respond to grieving colleagues by saying nothing out of fear of causing pain or reminding a griefstricken colleague of their loss by sharing their own experiences with grief.

•

There is widespread denial in corporate environments that workplace abuse and trauma significantly contribute to mental health decline at work.

•

The Me Too movement has had a transformational impact on the conversation surrounding the reality of workplace trauma and is helping to break the silence of trauma victims.

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SECTION 2: IDENTIFYING YOUR REALITIES Introduction Post-traumatic stress disorder (PTSD) is a psychological disorder that develops after experiencing unexpected, frightening, or traumatic events. These events can include exposure to severe injury, psychological abuse, actual or threatened death, and sexual violation. Most people experience fear and anxiety during and immediately after a traumatic event. Many trauma survivors recover naturally from these reactions over time; however, some go on to develop PTSD symptoms. A survivor is more likely to develop PTSD when they experience multiple traumas in succession or if they remain in a traumatic situation for an extended period. These emotional reactions are potent ways your body and mind help you cope with the effects of trauma. They are psychologically adaptive reactions designed to protect you from the aftermath of traumatic experiences. PTSD survivors commonly experience external reminders of the traumatic experience that lead to an acute stress response. These external reminders are called triggers. Memories of the traumatic events are called flashbacks and lead to the same acute stress response experienced during the actual traumatic event. (MacMillan, 2017). Complex PTSD (C-PTSD) develops when an individual is repeatedly exposed to multiple forms of trauma. This syndrome 107

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was recently identified, and the impact of chronic long-term trauma is a newly emerging field of research. Recovering from PTSD is the process of rewiring our brain, and many PTSD treatments are based on the foundations of brain research. Understanding how the brain reacts to trauma will help you appreciate that our reactions to traumatic experience are hardwired into all of us.

What is PTSD? Listen to your body and pay attention to what your mind is telling you while I walk you through some of the most common warning signs that you’re experiencing PTSD. Mental health professionals diagnose PTSD when someone continues to experience persistent trauma and stress-related symptoms for more than six months after the initial traumatic experience. PTSD symptoms can surface immediately after experiencing the trauma or can show up after a delay of several months. It is also common for PTSD survivors to experience depression, anxiety, and obsessive-compulsive thoughts. The connections among these closely-related mental health conditions and PTSD are explored later. If you’re experiencing symptoms of PTSD, it is essential to reach out for professional help as soon as possible. I share recommendations about how to research and connect with professional resources in your community later in this book. If you’re suffering in silence, please take the time to review those recommendations and take steps to get the support you need. Resources in your local community ready are willing to support 108

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you at any time. I share a strategy for finding and accessing these resources in Section 3. The Symptoms and Characteristics of PTSD Unique PTSD symptoms include • •

Re-experiencing the traumatic memory in a disturbing way; Experiencing intense negative moods or having negative thoughts associated with them. For example, believing it is your fault, feeling depressed, having obsessive thoughts about the experience, or feeling anxious;

• •

Avoiding thoughts, feelings, and situations that remind you of the event; and Feeling high levels of arousal after the event and feeling hypervigilant.

PTSD has these core characteristics: • • • • • •

It usually occurs after you go through a life-threatening event or a long-lasting trauma. Sexual assault, domestic violence, or child abuse all trigger trauma. Seeing something horrific happen to other people can also trigger PTSD. Doctors, police officers, and emergency workers who regularly deal with stressful situations may develop PTSD. Signs of post-traumatic stress can begin to appear one month or more after the event that triggered PTSD. A delayed reaction is relatively common. Symptoms may also be significantly delayed and not surface for years after the event.

Someone who experiences a traumatic event will usually have a strong emotional reaction, but not everyone goes on to develop PTSD. So let’s dig deeper into the symptoms and emotional reactions of PTSD. PTSD survivors find themselves reliving the event that triggered PTSD through flashbacks and nightmares. These episodes can seem so real that it’s like the event is happening all over again, with flashbacks of sounds, smells, physical sensations, and emotions. Flashbacks are a terrifyingly vivid experience. Everyday objects and events can trigger 109

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waking flashbacks. A trigger might be a sound or smell associated with the event, a location, a word, or a physical sensation. Why does someone who has experienced a traumatic episode relive it over and over? The brain is forcing the person to keep thinking about the incident, so they are prepared if another crisis happens. Sometimes the person might relive events and think about what he or she could or should have done to make things turn out differently, not that they could necessarily have changed the event as it happened. Survivor guilt is common for survivors of significant traumatic events, such as a plane crash or a terror event: “Why did I survive when those other people died?” Constantly reliving the traumatic event is exceptionally upsetting for someone with PTSD, and they will generally try to avoid it by using distractions, such as not seeing close friends and relatives, or by becoming emotionally numb. Avoidance and numbing are coping strategies that can take many forms, such as overworking or becoming immersed in a hobby, or drug or alcohol abuse—all things that help the person manage the aftereffects of the trauma. The third frequent indicator of PTSD is called hypervigilance, a state in which the person remains continually alert and unable to relax, as though always on the lookout for signs of danger. Often the hypervigilant state is accompanied by anxiety and insomnia. The function of the hypervigilant state is to ready the person for another impending traumatic incident. It acts as a type of reassurance that, this time, the person will be able to react in a way that helps keep them safe. Hypervigilance tends 110

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to be accompanied by chronic adrenaline production, which is the body’s way of ensuring there will be energy to spare if a crisis occurs. As PTSD symptoms develop, there are many possible physical, emotional, and behavioral signs. In contrast to the three common symptoms outlined above, the additional signs vary from person to person: •

Digestive upset such as chronic diarrhea or stomach pains

•

Muscle aches or pain

•

Headaches

•

Irregular heartbeat or palpitations

•

Depression

•

Anger, irritability, or aggressive behavior

The fight-or-flight response, also known as an acute stress response, is an automatic physiological reaction that occurs when faced with a mentally or physically terrifying situation. The response is triggered when the brain releases specific hormones that prepare your body to either stay to deal with a threat or run away to safety. The term represents the choice that our ancient ancestors had to make when faced with danger. Either way they chose, the physiological and psychological response to stress prepared them to react to the danger. This reaction is still wired into us and is completely healthy and adaptive. The body’s sympathetic nervous system activates in response to acute stress, followed by a sudden release of hormones. Cortisol 111

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is one of the hormones released in response to fear or stress by the adrenal gland. The sympathetic nervous systems stimulate the adrenal glands, and this triggers the release of adrenaline and noradrenaline hormones. Once released, these hormones rapidly increase heart rate, blood pressure, and breathing rate. After the threat is gone, it takes between 20 to 60 minutes for the body to return to its resting state. The Physical Signs of the Fight-or-Flight Response Rapid heartbeat and breathing: Increased heartbeat and respiration rate provide critical energy and oxygen to the body to fuel a rapid response to the real or perceived danger. Pale or flushed skin: As the stress response kicks in, blood flow to the skin’s surface is reduced, and more blood flows to the muscles, brain, legs, and arms. Your face may alternate between pale and flushed as blood rushes to your head and brain. The body’s blood clotting ability also increases to prepare for potential excessive blood loss in the event of an injury. Dilated pupils: Another typical response to fight or flight is the dilation of the pupils, which ensures more light reaches your eyes and enhances your visual awareness of the surroundings. Trembling: In the face of stress or danger, your muscles become tense and ready for action. This tension can result in trembling or shaking.

The fight-or-flight response can happen in the face of imminent physical danger such as closely witnessing a shooting or narrowly escaping a dangerous situation. It can also be triggered by a psychological threat, such as preparing to give a big presentation at work. In either case, by your body priming itself for action, you’re better prepared to perform under pressure. The stress created by the situation can be helpful, making it more likely that you’ll cope effectively with the threat. This type of stress can help you perform better in conditions where you’re 112

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under pressure to do well, such as on an exam or during a presentation. In cases where the threat is life-threatening, the fight-or-flight response can play a crucial role in your survival. Phobias are an example of a fight-or-flight response from a perceived threat. A person who’s terrified of heights may experience an acute response when they go to the top floor of a skyscraper to attend a meeting. PTSD survivors experiencing a flashback or vivid memory will experience an acute stress response and enter the fight-or-flight state. Panic attacks can occur when the flight-or-fight response becomes severe. Triggers can include sights, sounds, smells, or thoughts that remind you of the traumatic event. Specific triggers can bring back vivid memories of it, making you feel like you’re living through the traumatic event all over again. Some PTSD triggers are easy to identify, such as seeing a news report of an assault. Some triggers are not as clear-cut. Survivors may not be aware of their triggers because they haven’t made the mental connection or because they have become numb and detached to cope with the pain. Knowing your triggers and being able to anticipate and identify them will help you cope more effectively. By working with a therapist, you can learn and adapt new techniques to make it easier for you to live through, heal from, and change how you respond to those triggers. Common PTSD Triggers People: Seeing a person related to the trauma may set off a reaction, or someone may have a physical trait that’s a reminder. If someone with a beard mugged you, other bearded men may bring back traumatic memories. 113

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Thoughts and emotions: The way you felt during a traumatic event, such as afraid or helpless, can trigger symptoms. Things: Seeing an object that reminds you of the trauma can cue your symptoms. Smells: Memories are closely linked to smells. Someone who survived a fire could become upset by the smoky smell of a barbecue. Sounds: Memories of the trauma are recalled after hearing specific noises, songs, or voices. For example, hearing a car backfire may remind a veteran of gunfire. Tastes: The taste of something, such as alcohol, may remind you of a traumatic event. Places: Returning to the scene of a trauma is often a trigger. A similar situation, such as a dark hallway, may be similar enough to activate a reaction. Feelings: Some sensations, such as pain, are triggers. For survivors of assault, being touched on a particular body part may lead to a flashback. Television shows, news reports, and movies: Seeing a similar trauma often sets off symptoms. Words: Reading or hearing certain words could cue your PTSD. Situations: You may link similar scenarios to the trauma. Being stuck in an elevator might remind you of feeling trapped after a car accident. Anniversaries: It’s often hard to go past a date marked by trauma without remembering it. Many survivors of the Twin Tower attacks in New York City relive the events of September 11 on the anniversary.

Complex PTSD (C-PTSD) There is a growing realization among many mental health professionals that we should distinguish between PTSD that results from short-lived events and PTSD that develops from chronic, long-lasting traumatic events. While symptoms of PTSD apply well to people who have experienced a discrete or shortlived traumatic event, like a motor vehicle accident, natural 114

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disaster, or rape, they don’t always apply to people who have experienced chronic, repeated, or long-lasting traumatic events, such as ongoing workplace sexual violence, an abusive boss, domestic violence, or being held captive and abused. In these situations, the symptoms don’t entirely describe the psychological harm, emotional problems, and changes in how people view themselves and the world. Individuals with complex-PTSD (C-PTSD) typically suppress their emotional reactions to traumatic events. Emotional suppression happens because C-PTSD survivors tend to believe each recurring traumatic event “isn't a big deal.” They become desensitized to their persistent traumatic experiences, and grief becomes stuck in a holding pattern. This suppression of emotions can continue over a long period, either until a triggering event occurs, or until they find a safe emotional environment. C-PTSD recovery can only begin after the dam of suppressed emotion starts to break (Walker, 2014). C-PTSD is an emerging area of research and is being conceptualized as a distinct type of trauma with a unique constellation of symptoms and treatment options (Frayne, Skinner, & Sullivan, 1999; Hankin et al., 1999). First described by Dr. Judith Herman (2015) in her book Trauma and Recovery, C-PTSD develops when a person has experienced severe and repeated trauma. The victim perceives no way to escape and may be under the control of another person. For example, people living in refugee camps, those living with gang violence, incarcerated individuals, and civilians located in war zones are all likely to develop C-PTSD symptoms. Collective trauma can impact an entire nation after a large-scale 115

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traumatic event such as 9/11 in New York, the Boston Marathon bombings, or the London bombings in July 2005. The initial panic quickly subsides, but some people experience an ongoing feeling of uncertainty that leads them to question if a similar event will happen again. These individuals have also been found to develop C-PTSD. C-PTSD can develop from long-term and persistent trauma at work. Workers in certain professions—emergency responders, soldiers, peacekeepers, relief agency workers, and police officers—are exposed to multiple repeated forms of trauma and are at a higher risk of developing C-PTSD. Workplace bullying, harassment, discrimination, abuse, or sexual violence that take place repeatedly over an extended period increase the risk of developing C-PTSD (Merrill et al., 1998). The Symptoms of C-PTSD Many of the issues and symptoms experienced by C-PTSD trauma survivors go beyond the list of symptoms found in PTSD. Difficulties managing emotions: People with C-PTSD experience difficulties in managing their emotions. They may experience persistent sadness, severe depression, suicidal thoughts, or explosive anger. Covert anger is common with behaviors such as procrastination, performing tasks poorly, feigning forgetfulness when given tasks or ignoring instructions entirely, negativity or a hostile or critical attitude, and withdrawing or giving others the silent treatment. Changes in consciousness: Following chronic traumatic events, a person may repress memories of the traumatic event, experience flashbacks, or feel disconnected from reality. Changes in self-perception: The victim can experience feelings of helplessness, shame, stigma, guilt, detachment, and feel completely different from other human beings. Changes in how the victim views the perpetrator: A person with C-PTSD may feel like they have no power over a perpetrator. The victim may also become preoccupied with their 116

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relationship with a perpetrator, such as constant thoughts of wanting revenge. Changes in personal relationships These symptoms include problems with relationships, such as isolating themselves, distrusting others, or repeatedly searching for a rescuer. Changes in how they view the world: People exposed to chronic or repeated traumatic events may lose faith in humanity, change how they view the meaningfulness of life, or have a sense of hopelessness about the future.

Workbook Exercises Workbook Exercise 2-1: Understanding my situation Goal Recovery starts by understanding your current situation better. The more you know about yourself and how you want your life to be, the more you can begin to plan a path to get there. Thinking through this information may help you clarify what’s working and not working in your current situation. Later you can use this information to verify if you’re experiencing PTSD. Instructions To make clear decisions about your future and recovery, you must identify your true self. Looking at your life from a different perspective can often help you see yourself more clearly. •

Take a moment to think about the last time you let go of work. Perhaps you took a long weekend or an extended vacation. How did it feel to relax and enjoy life?

•

Now, think about how you feel at the end of the day or after a week at work. 117

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Elements of

•

Do you feel like yourself, or does it take you a while each night to re-find yourself?

•

Rate the elements of how and who you are in Workbook 1-2 to take inventory of how you’re doing at the moment. Good

Okay

Not So Good

Your current health

❑

❑

❑

Enjoying your life

❑

❑

❑

Who and How You Are

118

Why?

Identifying Your Realities

Elements of

Good

Okay

Not So Good

Making time for yourself

❑

❑

❑

Exploring and participating in your hobbies and interests

❑

❑

❑

Working toward reaching your dreams

❑

❑

❑

Who and How You Are

Why?

119

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Elements of

Good

Okay

Not So Good

Living in a way that lines up with your values

❑

❑

❑

Balancing your needs and those of others

❑

❑

❑

Other

❑

❑

❑

Who and How You Are

120

Why?

Identifying Your Realities

Notes

Workbook Exercise 2-2: Understanding my life situation Goal Before you can focus clearly on the future, it’s essential to take a look at your current situation. If some aspects of your life work well, you’ll want to keep those aspects intact. If certain areas of your life are problematic or not satisfying, you can find ways to alleviate them by making proactive changes to your life. Instructions Take a few minutes to review some of the elements of your life in the table below. •

Decide how you feel you’re doing with each of these elements.

•

Think of an example of what you enjoy doing for each of these critical elements. 121

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Elements of

Good

Okay

Your Life

Not So Good

Your social life

❑

❑

❑

Your time, hobbies, and recreational activities

❑

❑

❑

Your relationship with your children (if relevant)

❑

❑

❑

122

What do you enjoy doing? Think of an example.

Identifying Your Realities

Elements of

Good

Okay

Your Life

Not So Good

Your relationship with your partner (if relevant)

❑

❑

❑

Your interactions with your family

❑

❑

❑

Your financial situation

❑

❑

❑

What do you enjoy doing? Think of an example.

123

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Elements of

Good

Okay

Your Life

Not So Good

Balancing your needs with those of others

❑

❑

❑

Other

❑

❑

❑

Notes

124

What do you enjoy doing? Think of an example.

Identifying Your Realities

Workbook Exercise 2-3: Identifying my emotions Goal PTSD can activate an avalanche of emotions and traumatic memories, which can be confusing and overwhelming. In severe cases, they can be hard to understand or make you feel unable to move forward. Once you can identify what you’re feeling, you’ll have vital information to create a path forward. Emotional clarity will help you cope better with PTSD thoughts. Instructions Keep in mind that every emotion has three parts. All three can affect how you feel. 4. Your thoughts: Ideas or images that pop into your head when you’re feeling an emotion. 5. Your physical sensations: The physical changes you experience (for example, increased heart rate or nausea) when you’re feeling an emotion. 6. Your behavior: The action you feel like taking when 125

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you’re feeling an emotion. Sometimes you feel an emotion or an uncomfortable thought so strongly that it’s difficult to recognize other emotions you’re feeling. You might find yourself trying to push those emotions away or suppressing your uncomfortable thoughts, but either will make it difficult for you to identify your feelings. This exercise will help you tune into your emotions more clearly. Knowing how you’re feeling is very useful because it will give you the information you need to choose an appropriate coping strategy. Here are a few examples of typical emotions experienced by someone with PTSD. Emotion

Thoughts

Physical Sensations

Behaviors

Fear

“I’m in danger. Something terrible is going to happen.”

Racing heart, “tunnel vision,” shortness of breath

Getting away from a situation, “freezing,” crying

Sadness

“My situation is never going to change. I'm all alone in this.”

Low energy, slower heart rate, nausea

Isolating yourself, crying

Anger

“Life is unfair. Everyone’s out to get me.”

Racing heart, muscle tension, jaw clenching

Yelling, picking a fight, slamming doors

126

•

Take a few moments to identify all three parts of the intense emotions you feel when you experience traumatic memories and uncomfortable feelings.

•

A list of emotions provided in the table below will help you tune into typical reactions if you have PTSD.

Identifying Your Realities

Emotion

Feel

Annoyed

❑

Anxious

❑

•

If you are experiencing one of those emotions, think back to when you experienced an unexpected flashback or memory of the traumatic event.

•

Briefly summarize the elements below when you’re feeling this emotion:

•

Thoughts

•

Physical sensations

•

Action you feel like taking Thoughts

Physical Sensations

Action You Feel Like Taking

127

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Emotion

Feel

Betrayed

❑

Confused

❑

Denial

❑

128

Thoughts

Physical Sensations

Action You Feel Like Taking

Identifying Your Realities

Emotion

Feel

Defensive

❑

Depressed

❑

Distracted

❑

Thoughts

Physical Sensations

Action You Feel Like Taking

129

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Emotion

Feel

Distressed

❑

Disturbed

❑

Dissatisfied

❑

130

Thoughts

Physical Sensations

Action You Feel Like Taking

Identifying Your Realities

Emotion

Feel

Disgusted

❑

Disappointment

❑

Envy

❑

Thoughts

Physical Sensations

Action You Feel Like Taking

131

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Emotion

Feel

Fear

❑

Frustrated

❑

Guilt

❑

132

Thoughts

Physical Sensations

Action You Feel Like Taking

Identifying Your Realities

Emotion

Feel

Grief

❑

Hope

❑

Jealousy

❑

Thoughts

Physical Sensations

Action You Feel Like Taking

133

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Emotion

Feel

Negative

❑

Offended

❑

Optimistic

❑

134

Thoughts

Physical Sensations

Action You Feel Like Taking

Identifying Your Realities

Emotion

Feel

Regret

❑

Resentful

❑

Sad

❑

Thoughts

Physical Sensations

Action You Feel Like Taking

135

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Emotion

Feel

Shame

❑

Stressed

❑

Surprised

❑

136

Thoughts

Physical Sensations

Action You Feel Like Taking

Identifying Your Realities

Emotion

Feel

Troubled

❑

Upset

❑

Uncomfortable

❑

Thoughts

Physical Sensations

Action You Feel Like Taking

137

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Emotion

Feel

Unconcerned

❑

Unhappy

❑

Victimized

❑

138

Thoughts

Physical Sensations

Action You Feel Like Taking

Identifying Your Realities

Emotion

Feel

Vulnerable

❑

Worried

❑

Other

❑

Thoughts

Physical Sensations

Action You Feel Like Taking

139

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Notes

Workbook Exercise 2-4: Am I anxious? Goal Sometimes we suppress our emotions to make it easier to cope and get through the day. Completing this quick checklist will help you identify if you’re anxious, even if you’re not entirely consciously aware of feeling that way. Instructions •

Think back on how you’ve felt over the past month.

•

Review the statements below and choose how often you’ve experienced each of the following anxiety symptoms. Circle only one number in each row.

Symptom Experienced 1.

Pounding heart

2.

Sweating

140

Never

Rarely

Sometimes

Often

Usually

0

1

2

3

4

0

1

2

3

4

Identifying Your Realities

Symptom Experienced 3.

Trembling or shaking

4.

Shortness of breath

5.

Afraid or scared

6.

Nausea or abdominal distress

7.

Feeling dizzy or unsteady

8

Fear of losing control or going crazy

9.

Numbness or tingling sensations

10.

Chills or hot flashes

11.

Fear of dying

12.

Constant or persistent worry

13.

Feeling of choking

14.

Unable to relax

15.

The feeling of being unreal

16.

Nervous

17.

Feeling shaky or wobbly

Never

Rarely

Sometimes

Often

Usually

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

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Symptom Experienced 18.

Irritable or difficulty sleeping

19.

Trembling hands

20.

Avoid situations because of anxiety

21.

Feeling lightheaded or faint

Never

Rarely

Sometimes

Often

Usually

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

Adapted From: The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 5th ed., 2013). Refer to the criteria for panic and anxiety disorders.

Findings Now add up all the numbers you’ve circled to get your score. A higher score (the highest is 84) means you’re experiencing more signs of anxiety. If you’ve scored more items as 3 or 4, you’re likely feeling anxious.

Workbook Exercise 2-5: Am I depressed? Goal Sometimes we suppress our emotions to make it easier to cope and get through the day. Completing this quick checklist will help you identify if you’re depressed, even if you’re not entirely consciously aware of feeling that way. Instructions

142

•

Think back on how you’ve felt over the past month.

•

Review the statements below and choose how long you’ve experienced each of the following signs of

Identifying Your Realities

depression. Circle one number in each row.

How often have you been bothered by any of the following problems?

1.

2.

3.

4.

5.

6.

7.

Not at all

Several days

More than half the days

Nearly every day

Little interest or pleasure doing things

0

1

2

3

Feeling down, depressed, or hopeless

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

Feeling bad about yourself, like you’re a failure or have let yourself or your family down

0

1

2

3

Trouble concentrating on things, such as reading the newspaper or watching television

0

1

2

3

Trouble falling asleep, staying asleep, or sleeping too much

Feeling tired or having little energy Poor appetite or overeating

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How often have you been bothered by any of the following problems?

8.

9.

Moving or speaking so slowly that other people have noticed or being so fidgety or restless that you move around a lot more than usual

Not at all

Several days

More than half the days

Nearly every day

0

1

2

3

0

1

2

3

Thoughts of being better off dead or hurting yourself in some way

If you checked off any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

❑

Not difficult at all

❑

Somewhat difficult

❑

Very difficult

❑

Extremely difficult

Adapted From: The PHQ-9 was developed by Dr. Robert L. Spitzer, Dr. Janet B. W. Williams, Dr. Kurt Kroenke, and colleagues with an educational grant from Pfizer, Inc. No permission is required to use the PHQ-9.

Findings Now add up all the numbers you’ve circled to get your score. A higher score (the highest is 27) means you’re experiencing more signs of depressions. If you’ve scored more items as 2 or 3, 144

Identifying Your Realities

you’re likely feeling depressed. Notes

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Workbook Exercise 2-6: Am I having obsessive-compulsive thoughts? Goal Sometimes we suppress our emotions to make it easier to cope and get through the day. Completing this quick checklist will help you identify if you’re having obsessive-compulsive thoughts, even if you’re not entirely consciously aware of feeling that way. Instructions •

Think back on how you’ve felt over the last month.

•

Review the statements below and check off if you’ve experienced this type of obsessive-compulsive thinking in the last few days, in the past, or both. Check all that apply.

Aggressive Obsessions

Experienced Experienced in the last in the past few days

1.

The fear I might harm myself

❑

❑

2.

The fear I might harm others

❑

❑

3.

Violent or horrific images

❑

❑

4.

The fear I will blurt out obscenities or insults

❑

❑

5.

The fear I will do something embarrassing

❑

❑

6.

The fear I will act on unwanted impulses (e.g., to stab a friend)

❑

❑

7.

The fear I will steal things

❑

❑

8.

The fear I will harm others because I’m not careful enough

❑

❑

(e.g., hit or run over someone in the car) 146

Identifying Your Realities

Aggressive Obsessions 9.

The fear I will cause something terrible to happen

Experienced Experienced in the last in the past few days

❑

❑

❑

❑

(e.g., fire, burglary) 10. Other

Contamination Obsessions 1.

Excessive concern or disgust about my bodily waste or secretions

Experienced Experienced in the last in the past few days

❑

❑

(e.g., urine, feces, saliva) 2.

Excessive concern with dirt or germs

❑

❑

3.

Excessive concern with environmental contaminants

❑

❑

❑

❑

❑

❑

(e.g., asbestos, radiation, toxic mold, toxic waste) 4.

Excessive concern with household items (e.g., cleansers, solvents)

5.

Excessive concern with animals (e.g., insects)

6.

Bothered by sticky substances or residues

❑

❑

7.

Concerned I will get ill because of contaminants

❑

❑

8.

Concerned I will get others ill by spreading contaminants (Aggressive)

❑

❑

9.

I have no concerns about the consequences of contamination, other than how it might make me feel

❑

❑

❑

❑

10. Other

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Sexual Obsessions

Experienced Experienced in the last in the past few days

1.

Forbidden/persistent intense sexual thoughts, images, or impulses

❑

❑

2.

Aggressive sexual behavior toward others

❑

❑

3.

Other

❑

❑

Religious Obsessions

Experienced Experienced in the last in the past few days

1.

Excessive concern with sacrilege and blasphemy

❑

❑

2.

Excessive concern with right and wrong and morality

❑

❑

3.

Other

❑

❑

Obsession with the Need for Symmetry and Exactness 1.

Excessive concern with the need for symmetry and exactness

Experienced Experienced in the last in the past few days

❑

❑

❑

❑

❑

❑

(e.g., objects in my home must be checked and put in an exact position or something terrible will happen) 2.

Believing in magical thinking (e.g., concerned someone will have an accident unless things are in precisely the right place)

3.

148

Other

Identifying Your Realities

Miscellaneous Obsessions

Experienced Experienced in the last in the past few days

1.

Need to know or remember particular things

❑

❑

2.

Fear of saying certain things

❑

❑

3.

Fear of not saying exactly the right thing

❑

❑

4.

Fear of losing things

❑

❑

5.

Intrusive (non-violent) images

❑

❑

6.

Intrusive nonsense sounds, words, or music

❑

❑

7.

Extreme annoyance by certain sounds/noises

❑

❑

8.

Excessive concern with lucky/unlucky numbers in my life

❑

❑

9.

Concern that colors have a special significance and relate to my superstitious fears

❑

❑

❑

❑

10. Other

Health Obsessions

Experienced Experienced in the last in the past few days

1.

Excessive concern with illness or disease

❑

❑

2.

Excessive concern with a body part or an aspect of appearance

❑

❑

3.

Other

❑

❑

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Cleaning/Washing Compulsions

Experienced Experienced in the last in the past few days

1.

Excessive or repeated handwashing

❑

❑

2.

Excessive or repeated showering, bathing, toothbrushing, grooming, or toilet routine

❑

❑

3.

Taking extreme steps to prevent or remove contact with contaminants

❑

❑

4.

Other

❑

❑

Checking Compulsions

Experienced Experienced in the last in the past few days

1.

Checking locks, stove, appliances

❑

❑

2.

Checking that I did not/will not harm others

❑

❑

3.

Checking that I did not/will not harm myself

❑

❑

4.

Checking that nothing terrible did/will happen

❑

❑

5.

Checking that I didn’t make a mistake

❑

❑

6.

Checking related to extreme health concerns

❑

❑

7.

Other

❑

❑

Repeating Compulsions

Experienced Experienced in the last in the past few days

1.

Repeated rereading or rewriting

❑

❑

2.

Repeating routine activities

❑

❑

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Repeating Compulsions

Experienced Experienced in the last in the past few days

(e.g., in/outdoor, up/down from chair) 3.

Excessive or repeated counting

❑

❑

4.

Excessive or repeated ordering/arranging things

❑

❑

3.

Other

❑

❑

Hoarding/Collecting Compulsions

Experienced Experienced in the last in the past few days

1.

Excessive collecting and hoarding of things. (e.g., collecting and carefully reading junk mail, collecting old newspaper articles, sorting through garbage, and collecting lots of noncritical objects)

❑

❑

2.

Other

❑

❑

Miscellaneous Compulsions 1.

Excessive or repeated list making

❑

❑

2.

Excessive or repeated telling, asking, or confessing something

❑

❑

3.

Excessive or repeated touching, tapping, or rubbing

❑

❑

4.

Rituals involving blinking or staring

❑

❑

5.

Excessive or repeated measures to prevent harm, self-harm, or other terrible consequences

❑

❑

6.

Ritualized eating behaviors

❑

❑

7.

Superstitious behaviors

❑

❑

8.

The urge to pull out your own hair (Trichotillomania)

❑

❑ 151

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Hoarding/Collecting Compulsions 9.

Self-damaging or self-mutilating behaviors

10. Other

Experienced Experienced in the last in the past few days

❑

❑

❑

❑

Adapted From: Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), designed by Wayne K. Goodman and his colleagues, is used extensively in research and clinical practice to both determine the severity of OCD symptoms and to monitor improvement during treatment (Goodman, 1989).

Findings The higher the number of checkboxes you have checked, the more obsessive-compulsive thoughts you’re experiencing for the indicated timeframe. Notes

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Workbook Exercise 2-7: Describing the traumatic event that bothers me the most Goal Sometimes it can be challenging to understand and describe events that have traumatized us. This exercise will help you summarize the traumatic event that’s bothering you the most so you can describe it objectively and clearly. Instructions •

Take some time to answer each of the questions by referring to a problem you’ve experienced after a very stressful experience involving actual or threatened death, serious injury, severe stress, or sexual violence.

•

The event can be something that happened to you directly, something you witnessed, or something someone close to you experienced. Some examples are serious accidents, fires, disasters, physical attacks, sexual violence, abuse, war, homicide, or suicide.

•

Answer the questions by referring to the event that is currently bothering you the most.

Question

Notes

Briefly identify and describe the worst event (if you feel comfortable).

How long ago did it happen?

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Question

Did it involve actual or threatened death, serious injury, threat of job loss, or sexual violence?

Notes

❑

Yes

❑

No

❑

Did it happen to me directly?

❑

Did I witness it?

❑

I learned about it happening to a person I’m close to.

❑

I was repeatedly exposed to details about it as part of my job (for example, paramedic, law enforcement, doctor, military, or another first responder).

❑

Other (please describe)

❑

Accident or violence

❑

Natural causes

❑

Not applicable.

How did you experience it?

If the event involved the death of someone that you’re close to, was it due to some accident or violence or natural causes?

The event did not involve the death of someone I’m close to.

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Question

Notes

Give the event a summary, title, or name.

Briefly describe the event, if you’re able to identify one.

Workbook Exercise 2-8: Am I experiencing a trauma reaction? Goal Identify the symptoms of a trauma you’re experiencing and determine how severe your potential trauma reaction is. 155

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Instructions •

How often have you experienced each of the following in the last month, or since the traumatic incident (whichever is most recent)?

•

Circle the answer that is most true for you. Circle only one number per row.

Symptom

Never

Rarely

Sometimes

Fairly Often

Very Often

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

1.

Insomnia/difficulty getting to sleep

2.

Restless sleep

3.

Nightmares

4.

Waking up early in the morning and not falling back asleep

5.

Weight loss

6.

Feeling isolated from others

7.

Loneliness

8.

Low sex drive/lost interest in sex

9.

Sadness

10.

Flashbacks or sudden, vivid, distracting memories

0

1

2

3

4

11.

Spacing out/going far away in your mind

0

1

2

3

4

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Symptom 12.

Headaches

13.

Stomach and digestion problems

14.

Uncontrollable crying

15.

Anxiety attacks

16.

Trouble controlling my temper

17.

Difficulty getting along with others

18.

Dizziness

19.

Passing out

20.

Desire to physical hurt myself

21.

Thoughts of wanting to hurt others physically

22.

Sexual problems

23.

Sexual overactivity

24.

Fear of men

25.

Fear of women

26.

Unnecessary or overly frequent washing behavior

27.

Feelings of inferiority

Never

Rarely

Sometimes

Fairly Often

Very Often

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4 157

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Symptom 28.

Feelings of guilt

29.

Feelings that things are “unreal”

30.

Problems with my memory

31.

Feeling that I’m not always in my own body

32.

Feeling tense all of the time

33.

Having problems breathing

Never

Rarely

Sometimes

Fairly Often

Very Often

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

Add any additional comments or concerns that you have below.

Results

158

•

Each row shows a typical symptom of a trauma reaction.

•

The more rows you’ve circled with a score of 3 or 4, the more severe your trauma reaction. When you add up the numbers, the closer your total is to 132, the more severe your trauma reaction.

•

0–33, signs of a trauma reaction

Identifying Your Realities

•

34–66, signs of a moderate trauma reaction

•

67–99, signs of a severe trauma reaction

•

100–132, signs of an extreme trauma reaction

Notes

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Workbook Exercise 2-9: Could I be experiencing PTSD? Goal Identify the symptoms of a trauma you’re experiencing and determine if you may be experiencing PTSD. A professional assessment is required to get an accurate PTSD diagnosis; however, this checklist will give you are rough idea of whether you’re experiencing common PTSD symptoms. Instructions •

When you have time and energy, complete the exercise below to learn if you’re experiencing PTSD.

•

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each of the issues carefully and circle one of the numbers to the right to indicate how much you’ve been bothered by that problem in the past month.

In the past month, how much were you bothered by this problem?

Not at all

A little bit

Moderately

Quite a bit

Extreme

Repeated, disturbing, and unwanted memories of the stressful experience

0

1

2

3

4

2.

Repeated, disturbing dreams of the stressful experience

0

1

2

3

4

3.

Suddenly feeling or acting as if the stressful experience were happening again (as if you were back there reliving it)

0

1

2

3

4

1.

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Identifying Your Realities

In the past month, how much were you bothered by this problem?

Not at all

A little bit

Moderately

Quite a bit

Extreme

Feeling very upset when something reminded you of the stressful experience

0

1

2

3

4

Having intense physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)

0

1

2

3

4

Avoiding memories, thoughts, or feelings related to the stressful experience

0

1

2

3

4

Avoiding visible reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)

0

1

2

3

4

Trouble remembering important parts of the stressful experience

0

1

2

3

4

Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts that you’re a bad person, that there’s something seriously wrong with you, that no one can be trusted, and that the world is hazardous)

0

1

2

3

4

10. Blaming yourself or someone else for the stressful experience or what happened after it

0

1

2

3

4

11. Having strong negative feelings, such as fear, horror, anger, guilt, or shame

0

1

2

3

4

4.

5.

6.

7.

8.

9.

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In the past month, how much were you bothered by this problem?

Not at all

A little bit

Moderately

Quite a bit

Extreme

12. Loss of interest in activities that you used to enjoy

0

1

2

3

4

13. Feeling distant or cut off from other people

0

1

2

3

4

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)

0

1

2

3

4

15. Irritable behavior, angry outbursts, or acting aggressively

0

1

2

3

4

16. Taking too many risks or doing things that could harm you

0

1

2

3

4

17. Being “super alert,” watchful, or on guard

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

18. Feeling jumpy or easily startled 19. Having difficulty concentrating 20. Trouble falling or staying asleep

Adapted From: The PCL-5 is from Weathers, Litz, Keane, Palmieri, Marx, and Schnurr (2013). The scale is available from the National Centre for PTSD at www.ptsd.va.gov and is in the public domain.

Results

162

•

Each row shows a typical symptom of PTSD.

•

The more rows you’ve circled with a score of 3 or 4, the higher the likelihood you’re experiencing PTSD.

Identifying Your Realities

Notes

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The Brain and PTSD Brain research studies have identified changes in brain structures associated with PTSD and trauma. This summary was compiled from research studies by several research teams (Howard & Crandall, 2006; Bremner, 2006; Bremner, Elzinga, Schmahl, & Vermetten, 2008). Understanding how PTSD alters brain chemistry is guiding the development of treatment options. Brain research is also providing the answers to why only some people develop PTSD from trauma. How PTSD Changes the Wiring of the Brain The prefrontal lobe (responsible for language) •

The prefrontal lobe is adversely affected.

•

PTSD survivors may struggle to find the words to express what they’re thinking and feeling.

•

Trauma suppresses language abilities.

The amygdala (responsible for emotional regulation) •

The amygdala shows signs of physical enlargement.

•

Trauma has been shown to increase activity in the amygdala.

•

PTSD survivors can find it challenging to control their emotions.

•

Studies have shown that PTSD survivors exhibit hyperactivity in the amygdala in response to stimuli linked to their trauma.

The hippocampus (responsible for memory and experience assimilation) •

The hippocampus appears to be smaller.

•

Short-term memory loss is common for individuals with PTSD.

The medial prefrontal cortex (regulates emotion and fear responses)

164

•

The medial prefrontal cortex cannot regulate itself or function properly after trauma.

•

Trauma negatively impacts the functioning of the hippocampus, which disrupts the regulation of emotions.

•

PTSD can make you feel frightened no matter what you’re doing.

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The amygdala and hippocampus (responsible for memory) •

The amygdala and hippocampus show the most significant physical changes for individuals with PTSD.

•

Under normal conditions, when a memory is built or retrieved, the hippocampus blends all the elements of a memory from all the sensory areas. Initially, the hippocampus stores short-term memories, but when the conscious mind does not require them, the hippocampus processes these memories into other parts of the brain, creating longer-term memories.

•

The hippocampus reduces in volume for PTSD survivors and the recording of new memories and the retrieval of older memories in response to relevant environmental stimuli can become distorted.

•

The hippocampus is also responsible for distinguishing between past and present memories. Then PTSD survivors experience a flashback, they can lose their ability to discriminate between these experiences.

The ventromedial prefrontal cortex (regulates negative emotions such as fear) •

This region shrinks in individuals with PTSD.

•

The ability to regulate negative emotions is reduced.

•

The change to the ventromedial prefrontal cortex causes fear, anxiety, and extreme stress responses even when faced with things not connected, or only remotely connected, to their original trauma.

Source: Liberzon & Sripada, 2008; Rauch, et al., 2000.

During life-threatening emergencies, the brain stem suppresses the higher centers of the brain that handle rational thought. The brain stem is an evolutionarily old part of the brain that’s responsible for instinctive and automatic activities. During an emergency, this is an adaptive response because there’s no time to think about what to do next. A rapid and automated response is what’s needed to protect you from the severe threat. The threat induces an unconditioned reaction in the brain, which is called the unconditional stimulus. Once the danger is over, the prefrontal cortex is activated enough to send messages to the amygdala to stop the fight-or-flight response 165

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triggered by the brain stem. The body gradually returns to a resting state.

Figure 1: The brain’s emergency response after the PTSD survivor experiences the original traumatic event

Pre-Frontal Cortex

Amygdala

Original Traumatic Event (Unconditioned Stimulus)

m nste Brai

Shin et al. (2004) studied people with PTSD and found that the amygdala in these individuals showed elevated brain activity, while activity in their prefrontal cortex was dramatically reduced. The imagined or remembered threat induces a conditioned reaction in the brain, which is called the conditioned stimulus. It takes a PTSD survivor much longer to recognize that the perceived danger has ended because their amygdala is overactive and their prefrontal cortex is suppressed (Shin et al., 2001). Understanding the body’s natural fight-or-flight response is an excellent way to cope with PTSD symptoms. When you notice that you’re becoming tense, you can learn methods to calm down and relax your body. 166

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Figure 2: The brain’s emergency response after the PTSD survivor experiences trauma triggers

Pre-Frontal Cortex

Amygdala

Trauma Triggers (Conditioned Stimulus)

ns Brai

tem

Triggers in the environment result in the same emergency response the PTSD survivor originally experienced when the traumatic event happened.

A form of psychotherapy that’s proven to be helpful for PTSD survivors is cognitive behavioral therapy (CBT), which assumes that thoughts, feelings, and behavior are all connected. Individuals can heal by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses. CBT involves working collaboratively with a therapist to develop skills for testing and modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors.

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Figure 3: The brain’s emergency response after the PTSD survivor receives cognitive behavioral therapy

Pre-Frontal Cortex

Amygdala

Cognitive Behavioral Therapy

ns Brai

tem

Cognitive behavioral therapy trains the individual to force their prefrontal cortex to go online, which inhibits the amygdala and prevents an extreme emotional response while the trauma memory is activated.

CBT trains survivors to force their frontal lobe into an online state by teaching them to introduce thoughts that will test the reality of the perceived threat. The activated frontal lobe inhibits the amygdala and prevents the typical extreme emotional responses experienced by PTSD survivors, even while the trauma circuit is activated. This form of therapy reduces the tendency for PTSD survivors to experience a prolonged and acute stress reaction by significantly reducing its duration and intensity.

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The Health Impacts of PTSD A considerable amount of research has found a link between trauma and its negative impact on physical health. Existing studies have not been able to conclusively determine that PTSD causes poor health, however, but from what we know about PTSD, experts believe it is highly probable (Baron & Kenny, 1996; Acierno et al., 1999). PTSD may promote poor health by interacting with our biology and mental state. The National Center for PTSD and other laboratories around the world continue to study these mechanisms. Researchers hypothesize that the experience of trauma brings about neurochemical changes in the brain. These changes in the nervous system may have biological, psychological, and behavioral effects on our health. For example, they may create a vulnerability to hypertension and heart disease that could partially explain the increased rates of cardiovascular disorders in PTSD survivors. Neurochemical changes have also been linked to abnormalities in the thyroid, changes to hormone functioning, increased susceptibility to infections, and immunological diseases. The psychological and behavioral effects of PTSD on our health have been linked to higher incidences of depression and anxiety in PTSD survivors. Depressed individuals report more physical symptoms and access the healthcare system more often. There is a proven link between depression and cardiovascular disease for PTSD survivors. PTSD also may be related to poor health through symptoms of anxiety or panic. The evidence linking anxiety to cardiovascular disease is strong, 169

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but the precise mechanisms are unknown. Hostility and anger are other possible mediators of the relationship between PTSD and physical health. Hostility plays a crucial role in the development of cardiovascular disease. Incidence of poor health in PTSD survivors may be partially mediated by behavioral health risk factors such as smoking, substance abuse, poor diet, and lack of exercise. Little is known about how coping and social support relate to the health of PTSD survivors, but both likely play important roles (Freedman, et al., 2015). The Health Impacts of PTSD Schnurr (Schnurr, 1996; Schnurr & Green, 2004) reviewed a large amount of scientific research on this topic and identified these findings on the health impacts of PTSD: Cancer, Lung Disease, and Heart Disease

•

Several studies found that childhood abuse and neglect were related to an increase in these physician-diagnosed disorders.

Use Health Services More Often

•

People who have been traumatized are more likely to use health services to manage physical health issues.

•

Healthcare costs are higher among women who report a history of childhood abuse or neglect than women with no history of maltreatment as a child (Frayne et al., 1999; Hankin et al., 1999).

•

Individuals who report PTSD symptoms are more likely to have a higher number of physical health problems.

•

There is a clear association with PTSD for veterans and active duty personnel, civilians, firefighters, and adolescents (Schnurr, 1996).

Cardiovascular Health Impacts

170

•

Some evidence indicates that PTSD is related to cardiovascular, gastrointestinal, and musculoskeletal disorders.

•

PTSD was found to be associated with nonspecific ECG abnormalities, atrioventricular

Identifying Your Realities

conduction defects, and infarctions. Because the PTSD group in this study included only veterans with severe PTSD, we must interpret this study with caution. It is unknown whether men with less severe PTSD would show the same ECG abnormalities. Gastrointestinal and Musculoskeletal Systems

•

The gastrointestinal and musculoskeletal systems have also been shown to be associated with PTSD, but the relationship has not been as extensively researched as that between PTSD and the cardiovascular system.

•

Most studies done have gathered information about veterans, but a study of civilian young men and women found a relationship between gastrointestinal symptoms and PTSD. Similarly, researchers found that PTSD was related to musculoskeletal symptoms among male firefighters. Additional research is needed to learn more about how these and other bodily system troubles may be associated with PTSD.

Medical professionals are becoming more aware of the harmful effects of trauma on health. Early screening for PTSD is helping them address both the physical and psychological effects of trauma. There is a growing trend to integrate mental health and medical care when treating PTSD through the use of a multidisciplinary team made up of psychologists, psychiatrists, social workers, medical doctors, and rehabilitation professionals. This multipronged approach is designed to tackle the relationship between PTSD and health from a variety of angles, significantly increasing the overall success of the treatment. This multidisciplinary approach to PTSD dramatically decreases symptoms and reduces the need for psychiatric medication. It shortens the course of treatment and often eliminates the need for other psychosocial services such as ongoing case management (Goodman, Milliken, Theiler, Nordstrom, & Akerman, 2016).

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Multidisciplinary Treatment Plan for PTSD Hospitalization Each patient works with a multidisciplinary team that collaboratively develops a treatment plan. This approach has been particularly effective for PTSD recovery because the patient has access to multiple resources and perspectives to gain clarity on how and why they’re reacting to triggers. The psychological, emotional, physical, and behavioral aspects of PTSD recovery are all essential. The team works with the patient throughout their entire treatment at the hospital setting. Members of the multidisciplinary team include •

Psychotherapist/Psychologist

•

Psychopharmacologist/Psychiatrist

•

Team nurses

•

Substance abuse counselor

•

Social workers (usually a team of specialized social workers)

•

Group therapy facilitator

A facilitator helps patients find their way into group therapy and informal leisure activities within the patient’s local therapeutic community. This community helps build a support network for the patient that they can rely on after they leave the hospital. Social workers provide liaison contact with the patient's family, arrange family meetings, provide family therapy with the patient’s therapist, and work with the patient on practical issues such as applying to school, returning to work, preparing for job interviews, and making discharge plans when the patient is ready to leave the medical care facility. The main advantage of a multidisciplinary team is that each patient gets the most appropriate and personalized treatment. The team of experts considers every patient from a range of viewpoints, ensuring that the patient is offered the best possible treatment currently available. Multidisciplinary teams also improve communication between professionals and patients by speeding up and streamlining the referral process to any specialist needed, which reduces delays in starting treatment. The disadvantage of a multidisciplinary team is that it can be quite time intensive and resource dependent. Proper resourcing and funding are required for the professionals to allow the time necessary for regular team meetings.

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Additional PTSD Risk Factors Experiencing a traumatic event is the primary PTSD risk factor, but other factors influence the onset of PTSD: •

Being a child or adolescent

•

Being female

•

Experiencing violence at home

•

Having a learning disability

•

Having a mental disorder before the traumatic event

•

Lacking social support

•

Experiencing trauma over a more extended period

Women are four times more likely than men to develop PTSD symptoms, according to the Mayo Clinic (2010). Although the reason for this isn’t entirely apparent, many experts believe it’s because women are more likely to experience interpersonal violence, such as rape, putting them at more risk. PTSD and violence often go hand in hand. PTSD in military personnel occurs so frequently that names for the condition have existed since the U.S. Civil War, when it was called “soldier’s heart.” During World War I, it was called “combat fatigue,” and by the Vietnam era, people were calling it “shell shock.” Rates are particularly high in Vietnam veterans, with the National Institute of Mental Health (2010) estimating that about 19 percent of Vietnam vets developed symptoms after the war. PTSD was formally established as a distinct anxiety disorder in 1980 (Dryden-Edwards, 2010). Of children who have been exposed to trauma, 3 to 15 percent 173

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of girls, and 1 to 6 percent of boys, will develop PTSD, according to the National Center for PTSD (2007). PTSD is especially common in children and adolescents when they are exposed to violence or abuse. Up to 100 percent of children who witness the death or sexual assault of a parent eventually develop PTSD, according to the National Center for PTSD (2007), as do 90 percent of sexually abused children, and 77 percent who witness a school shooting (Mayo Clinic, 2010; National Institute of Mental Health, 2010).

Synopsis

174

•

Mental health professionals diagnose PTSD when someone continues to experience persistent trauma and stress-related symptoms for more than six months after the initial traumatic experience.

•

PTSD survivors find themselves reliving the event that triggered their PTSD through flashbacks and nightmares; this is exceptionally upsetting for someone with PTSD, who generally tries to avoid these episodes using distractions or by becoming emotionally numb.

•

Anything that reminds a PTSD survivor of what happened right before or during the trauma can become a potential trigger for symptoms.

•

The fight-or-flight response, also known as the acute stress response, is an automatic physiological reaction that occurs when faced with a terrifying situation that is activated by PTSD triggers.

Identifying Your Realities

•

Complex PTSD develops when a person has experienced severe and repeated trauma, has no way to escape from a traumatic situation, or is under the control of another person who denies them escape.

•

It is common for individuals with PTSD to experience other related mental health conditions such as depression, anxiety disorder, or obsessive-compulsive disorder.

•

Brain research studies have identified changes in brain structures associated with PTSD and trauma.

•

Cognitive behavioral therapy trains PTSD survivors to rewire their brain by teaching the frontal lobe to block the automated extreme emotional responses experienced.

•

Research has found a link between trauma and a negative impact on physical health.

•

PTSD survivors are exposed to behavioral health risks through the adoption of unhealthy behaviors such as smoking, substance abuse, poor diet, and lack of exercise.

•

Early screening for PTSD is helping medical professionals address both the physical and psychological effects of trauma.

•

PTSD and violence often go hand in hand, which has been frequently observed in a high percentage of military personnel returning from combat.

•

PTSD is especially common in children and adolescents when they are exposed to violence or abuse.

•

Women are four times more likely than men to develop 175

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PTSD symptoms; it has been hypothesized that women are more likely to experience interpersonal violence, such as rape, which puts them at a higher risk of developing PTSD.

176

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Building Your Action Plan

SECTION 3: BUILDING YOUR ACTION PLAN Introduction This workbook section walks you through the steps to build your recovery action plan, which is the foundation of an effective path to recovery that you control. I begin this section by encouraging you to become a selfadvocate, so you can ask for what you need, clearly communicate what you want, and inform people about your thoughts and feelings. Being your own advocate is a great way to own your healing process and get the support you need throughout your recovery journey. When you have selfadvocacy skills, you’re in control of your recovery and will make the best life decisions for you. Next, I discuss the most efficient and effective strategies for researching support professionals and creating a short list of local professional support options. I cover targeted online searches and how to find professional organizations you can contact to verify the credentials and the reputations of support professionals. This information will help you narrow down your list so you can select a few to meet to see if there’s a fit.

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Recovery Professionals When past trauma is triggered, traumatic memories and emotions can leave us feeling alone, but expert PTSD recovery supports are there to help us build a bridge from that isolation to a life that integrates our network of friends, family, and social supports.

The Broad Categories of Counselors Counseling is a collaborative process between a professionally trained counselor and their client. Professional counselors help their clients do the following: •

Identify goals and find potential solutions to problems that cause them emotional distress

•

Help improve communication and coping skills

•

Strengthen self-esteem and self-image

•

Promote behavior changes that support mental health

Individual Counsellor. Individual counselors work one-on-one with their clients and provide support and facilitate personal growth during challenging times. They help you tackle life challenges such as anger, depression, anxiety, substance abuse, relationship problems, marital issues, effective parenting skills, school difficulties, and career changes. Couples Counsellor. Every couple experiences highs and lows in their levels of intimacy and harmony. Couples counselors address relationship stagnation, intimacy issues, conflict resolution, and expressions of aggressive behavior. The goals 180

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include disrupting unhealthy relationship patterns, slowing down cycles of negative behavior, and re-establishing realistic relationship expectations. Family Counsellor. Family counselors work with an entire family for several sessions and meet with individual family members when necessary. They address parenting concerns, sibling conflict, loss of family members, new members entering the family, dealing with a significant move, and they support the entire family through a major life change. The goals include improving communication, reducing family stress, improving family closeness, and assisting with effective parenting. Group Counsellor. Group counseling helps participants understand they’re not alone; they can learn from others who have been through similar experiences. Group sessions are facilitated by a professional group counselor. Groups usually have up to eight participants, one or two group leaders, and revolve around a common topic such as anger management, self-esteem, divorce, domestic violence, recovery from abuse and trauma, and substance abuse. This peer learning environment can help motivate individuals to work through their issues. Group members can report their progress, share insights, and ask for support from the group. This environment gives participants access to multiple points of view and an understanding of strategies that have been effective for other group members.

The Broad Categories of Psychotherapists Like counselors, psychotherapists interact with clients to 181

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facilitate positive adaptive changes in their thoughts, feelings, and behaviors. Psychotherapists also work with individuals, couples, and groups. A licensed psychotherapist obtains a master’s or doctorate degree and completes a supervised clinical residency. Registered psychotherapists are licensed, certified, or registered by a government or professional agency. Substance abuse counselors, ordained priests, ministers, and rabbis can also practice psychotherapy. In some regions, a person with a master’s degree in psychology can practice psychotherapy. These following licensed mental health professionals use psychotherapy in their daily work: •

Psychiatrists

•

Registered psychiatric nurses

•

Clinical social workers

•

Clinical psychologists

•

Marriage therapists

•

Family therapists

•

Licensed counselors

Psychotherapists specialize in one or more treatment approaches:

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•

Behavioral therapy

•

Interactive group therapy

•

Psychodynamic therapy

•

Psychoanalysis

•

Biofeedback

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•

Meditation

•

Relaxation training

Career Counsellors Career counselors are problem solvers who listen to and learn about their clients so they can help guide customized career decisions. They discuss career issues, challenges, and opportunities with you in a safe, confidential, and secure environment. These counselors complete a post-graduate degree in psychology or a diploma in counselling psychology. They are often experts in specific fields or domains such as engineering, management, technology, and hospitality. The Goals and Support Offered by Career Counsellors Encouraging clarity of thought: Teach planning, scheduling, and strategizing techniques to help you focus on complex career decisions. Changing unwanted behavior patterns: Facilitate the transformation of unwanted behavioral patterns limiting your career success. Building confidence through insight: Diagnose and help you understand the hurdles in your career path. This insight will help you develop the confidence and strategies to overcome them. Removing career frustration: Choosing your best career can be a demanding journey with emotional ups and downs. Career counselors will help you work through any distracting frustrations. Providing expert career resources: With their help, you’ll be able to target the resources you need to make informed career decisions. Inspiring through role models: Career counseling can help you connect with role models and mentors for inspiration and motivation. 183

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Selecting the right career through a collaborative process: Career counselors are experts at assessing aptitudes, personality, interests, and skills. This information will help you evaluate your best career options from the available and relevant choices.

Life Coaches Life coaching is distinctly different from consulting, mentoring, advice, therapy, or counseling. Life coaches focus on generating concrete results that move the client in the direction they desire. A life coach can be an invaluable resource to help navigate a major life transition, act as support to reach a specific goal, or create a strategy to solve a challenge in your life. These experts are trained to provide the questions, framework, exercises, and accountability needed to initiate positive change in your life. Life coaches examine what is going on right now, identify potential obstacles or challenges, and help you choose a course of action that will make your life what you want it to be. More Information About Life Coaches Life coach help address some or all of these areas of your life and goals: Lifestyle • •

Identifying your passion Becoming more organized

Life Transitions

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• • •

Successfully navigating a life transition Getting out of a rut in life Dealing with a divorce

•

Finding an ideal partner

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Health and Wellness •

Working through psychological barriers or fears

• • •

Helping to start a healthy lifestyle Finding more fulfillment in life Finding time to enjoy life more Learning to become a better partner

• •

Fulfilling your personal and emotional needs Balancing personal life and professional life

Career • • • •

Setting up goals and objectives Starting or growing a business Advancing or planning a career or business Becoming a better communicator or presenter

• •

Building strategies to get promoted at work Becoming successful

Financial • •

Making financial goals for financial security Fulfilling your financial needs

Social Workers Social workers serve people in need by looking at many different aspects of a problem, from the individual to the societal, from the psychological to the political. Common ways social workers work with clients include providing counseling, therapy, and education, and connecting clients to appropriate public or private resources. Child, Family, and School Social Workers. These social workers help children, families, and the elderly work toward resolving their problems. They place children in foster care and 185

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assist parents looking to adopt. They connect struggling parents with resources to help better care for and raise their children. School social workers in particular work with students and teachers to address bullying, learning disabilities, and other problems at school. Medical and Public Health Social Workers. These social workers help the seriously ill and those with chronic health problems to access public resources and find adequate care and services such as nutrition classes and nursing. They often play a crucial role in helping clients navigate the many healthcare and public service systems that provide care. They also offer counsel to clients and their families about coping with the effects of illness. Mental Health and Substance Abuse Social Workers. These social workers help people with a wide variety of mental health and substance abuse issues. They help connect clients with appropriate psychotherapy resources and find them financially accessible rehabilitative programs or long-term mental healthcare. They may also participate in outreach and preventive programs that identify people in need and proactively address issues before they become severe or lifethreatening.

Psychologists Psychologists seek to understand and explain thoughts, emotions, feelings, and behavior. Some psychologists work independently, conducting research, and others work directly with clients. They can also be part of a healthcare team, 186

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collaborating with physicians, social workers, and other health professionals to treat illness and promote wellness. Psychologists complete graduate training in psychology and require a doctorate followed by several years of supervised work with clients. Like psychiatrists, psychologists use the Diagnostic and Statistical Manual of Mental Disorders (DSM) to assess people who are experiencing symptoms of psychological illness. They often use psychological tests such as personality tests, clinical interviews, and behavioral assessments to understand their clients better. Private Practice. Psychologists in private practice set their own hours; many are part-time independent consultants. School Psychologists. These psychologists work in public schools from nursery school through college. They also work in private schools, universities, hospitals and clinics, community treatment centers, and independent practice. Hospital Psychologists. Psychologists employed in hospitals, nursing homes, or other healthcare facilities may also have evening or weekend shifts. Clinical Psychologists. Clinical psychologists specialize in mental and emotional disorders. Many specialize in a specific area such as depression, eating disorders, anxiety, personality disorders, drug addiction, and issues related to children and adolescents. Educational Psychologists. An educational psychologist focuses on human learning processes. These psychologists tend to work in educational centers as counselors and help students with learning disabilities learn more effectively by providing them 187

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with the necessary resources to help them overcome their learning limitations. Neuropsychologists. Neuropsychologists study how changes to the central nervous system and brain affect a person’s mental functioning. Physical trauma, a stroke, or a tumor all cause neurological changes. Neuropsychologists also specialize in the early diagnosis and treatment of dementia. Social Psychologists. Social psychologists specialize in human behavior and the psychological factors that influence social interactions. They focus on our interpersonal relationships, culture, prejudices, and attitudes we have toward other people. They also help people with mental illness reintegrate into society and develop group therapies that serve minorities or marginalized groups. Occupational Psychologists. Occupational psychologists focus on psychological issues and support in professional work environments. They typically work in education, human resources, and occupational health departments. They have an in-depth knowledge of human motivation and leadership and can help improve the efficiency of workers with psychological issues. Sexologists. These psychologists specialize in the diagnosis and treatment of issues in intimate relationships. Their goal is to improve the sexual health of people with mental health and physical or sexual issues. Sexologists treat psychological issues related to sexual desire, arousal, and orgasms. They work with couples, individual clients, and sometimes coordinate care with marriage counselors. 188

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Psychiatrists Psychiatrists are physicians who evaluate, diagnose, and treat patients affected by a temporary or chronic mental health problem. Common categories of mental illness psychiatrists treat are depression, anxiety, hallucinations, and delusions. They must have excellent communication skills and a high degree of emotional intelligence to understand patients’ emotional and psychological issues and formulate the best course of action for their treatment. Psychiatrists don’t treat patients with epilepsy or patients who have suffered a stroke or are in treatment for brain cancer. However, these disorders may cause mental health issues for some patients, and psychiatrists get involved in these situations. Psychiatrists first attend medical school and become medical doctors (MDs). Then they complete an additional four years of residency training in mental health. This residency often involves working in the psychiatric unit of a hospital. They also work with a wide variety of patients, ranging from children to adults, who may have behavioral problems, emotional difficulties, or a psychiatric disorder. Psychiatrists need to have an excellent understanding of basic psychology and possess psychotherapy skills to attempt to influence a patient’s disorder so they require less medication. Many psychiatric disorders, such as depression, anxiety, and specific phobias, can be effectively treated using only psychotherapy. Psychiatrists prescribe medications only when counseling and therapy fail to produce noticeable results. Psychiatrists may choose to specialize further by completing a 189

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fellowship in an area like neuropsychiatry, geriatrics, child or adolescent psychiatry, or psychopharmacology.

Finding Professional Support Your first challenge when researching your recovery options is finding a professional to help you on your journey. In treating a mental health condition, it’s essential to find a support professional who is trustworthy and knowledgeable—one who will become your ally. It may take a little time and persistence to locate this person (or team of people), but following the steps below will increase your chances of finding the support that matches your needs and makes you feel comfortable.

Step 1: Think About the Support You’re Looking For People have different reasons to consult a mental health professional. So, first answer these questions: Are you looking for someone who is licensed to prescribe medication? Are you looking primarily for someone to talk to? Most people treating a mental health condition have at least two professional supports, one focusing on medication therapies (the biological side) and the other on emotional or behavioral therapies (the mind side). Physician Support • 190

If you haven’t yet talked to a physician, you should see one for a physical exam, since many illnesses can mimic

Building Your Action Plan

symptoms of mental illness. Even if you don’t think your condition requires medical treatment, talk about your symptoms and try to get a diagnosis. Primary care doctors are essential allies in managing your health’s “big picture.” •

If you have a mental health condition that may benefit from medication, you should probably consult a mental health specialist, such as a psychiatrist, rather than relying on your primary care doctor. The specialist will have more experience treating PTSD.

Mental Health Support •

If you’re seeking help with emotions, behaviors, and thinking patterns, you should talk to a therapist or counselor. They both have specialties, so you should find one with expertise and experience treating PTSD.

Other Support Resources •

If you have to wait for an appointment, you can start using other support resources in the meantime. Local peer support groups are often available for free.

•

Your local mental health agency may be able to connect you with licensed peer specialists.

•

Visit a local community center to learn more about available support resources.

Social Work Support •

If you need assistance with housing or employment, have multiple health challenges, or difficulties affording treatment, you’d benefit from having a social worker on your treatment team. 191

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•

Your doctor, local hospital, or local healthcare hotline can connect you with a social worker.

Step 2: Gather Referrals If This Is an Emergency Situation If it’s an emergency, please go immediately to your closest emergency department. If you’re feeling suicidal or in crisis, immediately call your local suicide and crisis hotline to get support. The person on the other end of the line will help guide your next step. If You Have Health Insurance If you have health insurance, start by calling your insurer’s information number. Ask for phone numbers of professionals in your area who accept your insurance plan. Try to get at least three names, just in case. Now would be a good time to ask for clarification of your insurance benefits. Here are some questions you can ask: •

Can you make a direct appointment with a psychiatrist, or do you need to see a primary care doctor first for a referral?

•

How does your plan cover visits to a psychotherapist? Therapy coverage can vary significantly between insurance plans.

If You Don’t Have Health Insurance or You Have Public Health Care Coverage If you don’t have supplementary health insurance or if you have 192

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public health care coverage, your first stop should be your community mental health center or your doctor. •

You can find the phone numbers and address your local community mental health center using a search engine or by visiting a public library.

•

If you need help with a specific condition such as addiction, you can ask for a referral from your primary care doctor, and they will connect you with the right specialist.

Finding Licensed Professionals A licensed mental health professional has undergone a rigorous screening process, meets strict education requirements, has demonstrated a certain number of mandatory hours of professionally supervised work, and must abide by a strict code of conduct. Finding a professional who meets these standards will give you peace of mind about receiving the highest quality care possible. Licensing bodies are there to serve the community they have jurisdiction over and have the mandate to offer information to anyone looking for a licensed professional in that field. All licensing bodies maintain a directory you search to find a licensed professional in your area. Many licensing bodies have a phone number you can call for assistance. If a support professional is recommended to you, you can contact the licensing body to verify their professional record and credentials. It is always advisable to check with a local licensing body and verify their credentials and reputation. 193

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Step 3: Scheduling Your First Meeting If you’re finding it challenging to call to schedule an appointment, ask a friend or family member to call for you. If it’s your first time seeking a diagnosis or assessment, tell the person on the phone to reserve enough time for a more indepth initial conversation. If there’s a waiting list, schedule an appointment, but then call the other numbers on your list. You can always cancel that appointment if you find someone else sooner. Another way to get an appointment sooner is to join a cancellation list. If you feel you can’t wait weeks or months for help, see your primary care doctor as soon as possible to get treatments and support to bridge the gap until you’ve assembled your team.

Step 4: Ask Questions During your first visit with a support professional, you’re seeking advice, but you’re also shopping around. Be honest that you’re looking for someone you can work with long-term. You really need to ask yourself, “Do I feel comfortable with this person?” Even they have an excellent reputation, you have to be comfortable working with them on your recovery. You should feel that they’re on your side. Here are a few helpful questions you could ask:

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•

Have you worked with people similar to me? For how long?

•

How will we work together to establish goals and evaluate my progress?

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If having a support professional who understands and respects your cultural background is essential to you, NAMI (www.nami.org) and the Canadian Mental Health Association (cmha.ca) both offer useful tips to help find the right professional for you.

Step 5: Build a Professional Working Relationship The fundamental goal of counseling is to help you resolve your issues and improve your emotional well-being. Establishing an open and trustworthy relationship with your support professional creates the foundation for effectively reaching your goals. Building genuine connections from a trusting support is possible when these factors exist: 1. They are empathetic. Empathy is one of the most important characteristics of an effective counselor. An abundance of sensitive emotions will be brought forward during recovery and it’s the support professional’s job to help you feel understood and respected 2. They focus is on you. Counseling requires a great deal of listening. It’s the job of the support professional to stay focused and give you their full attention so they gain insight, make an accurate assessment, and ultimately develop a suitable recovery plan. 3. They’re patient and flexible. You set the pace of your recovery and your counselor must remain patient and flexible for you to successfully achieve your goals. Goals may be tied to a timeline but depending on how slowly, 195

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or quickly, you progress with your recovery, your support professional may choose to modify and evolve their treatment. 4. Your relationship is professional. Effective treatment requires clear boundary between being friendly in nature and being a “friendship.” Crossing that boundary can have serious implications on a treatment’s effectiveness and are grounds for you to file a professional ethics complaint. 5. Objectives are clearly set. Professionals will establish clear objectives, based on your specific issues and needs. 6. They are prepared. A competent support professional will prepare for each session by reviewing notes from previous sessions and developing a clear and organized treatment plan that matches your goals. 7. Proper procedures are followed. Your support professional is required to ask for your informed consent before administering treatments and therapies. It’s a legal requirement imposed on all support professionals. 8. Confidentiality is respected and protected. A professional always maintains the confidentiality of every patient. Sometimes the first person you visit might not be the right fit or lack experience with your particular issues. Move on to the next phone number on your list and keep looking. Remember that you’re recruiting team members to help you in the long term. With a little persistence, you’ll find people who will listen to you, consider your perspective, and work with you to improve your sense of well-being (Read, Stern, & Wolfe, 1997). 196

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Workbook Exercises Workbook Exercise 3-1: Building your coping strategies Goal Review the emotions you’re experiencing and think about what coping strategies would help you manage them. Instructions •

Refer back to the emotions you identified in the Section 1 workbook exercises.

•

In those exercises, you identified at least one or two thoughts, physical sensations, and behaviors connected to the emotions you’re feeling. You can also refer to the list below and select the ones that apply to you.

•

Now think about the type of coping strategy that might best manage those emotions. Take a few notes in the table below to remind you later. For example, if you’re experiencing an emotion that causes increased heart rate and muscle tension, you may want to try a coping strategy that reduces those physical sensations, such as muscle relaxation, medication, or deep breathing.

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Emotion

Identified Emotion

Annoyed

❑

Anxious

❑

Betrayed

❑

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Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Confused

❑

Denial

❑

Defensive

❑

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Depressed

❑

Distracted

❑

Distressed

❑

200

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Disturbed

❑

Dissatisfied

❑

Disgusted

❑

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Disappointment

❑

Envy

❑

Fear

❑

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Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Frustrated

❑

Guilt

❑

Grief

❑

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Hope

❑

Jealousy

❑

Negative

❑

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Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Offended

❑

Optimistic

❑

Regret

❑

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Resentful

❑

Sad

❑

Shame

❑

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Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Stressed

❑

Surprised

❑

Troubled

❑

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Upset

❑

Uncomfortable

❑

Unconcerned

❑

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Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Unhappy

❑

Victimized

❑

Vulnerable

❑

Coping strategy if you identified the emotion

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Emotion

Identified Emotion

Worried

❑

Other

❑

Notes

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Coping strategy if you identified the emotion

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Workbook Exercise 3-2: Five important questions to ask yourself Goal Answer six essential questions that will help guide the development of your recovery plan. Instructions •

Take a few minutes to answer these critical questions.

Question 1.

Details and Notes

What would I rather be investing my time and energy in?

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Question 2.

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What is my personal mission?

Details and Notes

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Question 3.

Details and Notes

What are my top three values? Value 1

What are my top three values? Value 2

What are my top three values? Value 3

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Question 4.

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What pivotal experiences have made me who am I today?

Details and Notes

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Question 5.

Details and Notes

What obstacles stand in the way of me making a change?

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Question 6.

216

What strengths can I draw on during my transition?

Details and Notes

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Workbook Exercise 3-3: Defining your S.M.A.R.T. recovery goals Goal This exercise will walk you through the process of setting effective recovery goals. Effective goals have similar characteristics, and this acronym can help you remember them: •

S = Specific

•

M = Measurable

•

A = Attainable

•

R = Realistic

•

T = Timely

Instructions The following guidelines will help you set healthy and S.M.A.R.T. recovery goals. Be realistic: You will only hurt yourself if you set unattainable goals. Don’t set yourself up for failure. Establish goals that stretch you but are realistically within reach of that stretch. •

Unrealistic goal: I will land my dream job by the end of the week.

•

Realistic goal: I will find at least part-time employment in the next six weeks.

Be specific: Goal setters often make the mistake of creating vague goals, which don’t provide enough guidance for the steps necessary to reach the goal. 217

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•

Non-specific goal: Get a job.

•

Specific goal: Obtain employment at a minimum of 30 hours per week and $15 per hour.

Break it down into steps: Once you have a specific, realistic goal, break it down into steps that you’ll complete to reach it. Even if you’ve narrowed your goal’s focus, you’ll need to come up with concrete smaller goals that make up the larger objective. Let’s say your main goal is to secure employment at a minimum of 30 hours per week and $15 per hour. The following steps could be the smaller steps that lead to it: •

Update my resume in the next week.

•

Search for jobs online for one hour each day.

•

Submit at least two job applications per day after the resume is complete.

Set measurements: How will you know if you’ve met your goal? Some goals are easier to measure than others. If your goal is employment, a full-time job could be the measure of success. It can be more challenging to set a measurement for a relationship goal, but it is still possible. For example, if you hope to restore a broken relationship, a measure of goal success could be sending an apology letter or setting up a meeting with that person. Set time limits: Don’t leave your goals open ended because this tends to create a “someday” mode that rarely results in goal attainment. Goals work better with deadlines to spur us into action. • 218

Limitless goal: Obtain employment at a minimum of 30

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hours/week and $15/hour. •

Timely goal: Obtain employment at a minimum of 30 hours/week and $15/hour within the next six weeks.

Forgive and learn: Know that, as you plan your goals, you may have a few setbacks along the way. However, experiencing speed bumps doesn’t mean you’ve failed; it simply means you’re human. If you don’t reach a goal in the time parameters you set, forgive yourself, accept the reality of the situation, and give yourself room to grow and learn from the process. Do not excuse or rationalize away poor choices. It doesn’t mean you accept imperfection; just accept that you won’t reach every goal you set in the way you originally planned. Be flexible: If you’re unable to meet a goal, or it becomes clear the goal is no longer viable, change it. These are your goals, and it is essential to own them while you learn and evolve. Part of the recovery process is developing new healthy habits, and your goals may need to change as you do. Not all circumstances are in your control, so be prepared to revise time lines, update specifics, or create entirely new goals as needed. Some goals can be put on hold or accomplished differently. It is vital to make new goals, not simply discard the old ones. Find helpful resources: Resources are available that can help inform your recovery goals. Support groups, family, friends, online resources, and therapists are a few of the resources at your disposal. Embrace accountability: Don’t run the marathon alone. As you set goals, could you share them with someone you trust? That could be a friend, a member of a support group, a mentor, a 219

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sponsor, or a family member. Ask them to hold you accountable for both the small and large steps. Knowing they will be asking about your progress. Goal 1 What is your goal (in one sentence)?

What are the benefits of achieving this goal? Questions What do I want to accomplish? Specific

Why do I want to accomplish this? What are the requirements? What are the constraints? How will I measure my progress?

Measurable

Attainable

How will I know when I’ve accomplished my goal? How can the goal be accomplished? What logical steps should I take? Is this a worthwhile goal? Is this the right time?

Relevant

Do I have the necessary resources to accomplish this goal? Is this goal in line with my longterm objectives?

Timely 220

How long will it take to accomplish this goal?

Goal

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When is the completion of this goal due? When am I going to work on this goal?

Action Plan What specific steps must you take to achieve your goal? Task to complete

Expected completion date

Date actually completed

Obstacles/Challenges What obstacles stand in the way of you achieving your goal? Obstacle

How will you address the challenges if/when they arise?

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Accountability When working toward achieving a goal, it is helpful to have one or two people you agree to check in with regularly. Keeping others informed on your progress can be a useful external motivator. Who can you share your goal with? Talk with one or two individuals who will want to see you achieve your goal. Explain to them why achieving this goal is essential to you. Ask if they’ll support you and hold you accountable in reaching your goal. Select and agree upon future dates/times you will report updates on your progress. Person

222

Frequency of status check-ins

Method of communication

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Goal 2 What is your goal (in one sentence)?

What are the benefits of achieving this goal? Questions

Goal

What do I want to accomplish? Specific

Why do I want to accomplish this? What are the requirements? What are the constraints? How will I measure my progress?

Measurable

Attainable

How will I know when I’ve accomplished my goal? How can the goal be accomplished? What logical steps should I take? Is this a worthwhile goal? Is this the right time?

Relevant

Do I have the necessary resources to accomplish this goal? Is this goal in line with my longterm objectives?

Timely

How long will it take to accomplish this goal? 223

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When is the completion of this goal due? When am I going to work on this goal?

Action Plan What specific steps must you take to achieve your goal? Task to complete

Expected completion date

Date actually completed

Obstacles/Challenges What obstacles stand in the way of you achieving your goal? Obstacle

224

How will you address the challenges if/when they arise?

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Accountability When working toward achieving a goal, it is helpful to have one or two people you agree to check in with regularly. Keeping others informed on your progress can be a useful external motivator. Who can you share your goal with? Talk with one or two individuals who will want to see you achieve your goal. Explain to them why achieving this goal is essential to you. Ask if they’ll support you and hold you accountable in reaching your goal. Select and agree upon future dates/times you will report updates on your progress. Person

Frequency of status check-ins

Method of communication

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Goal 3 What is your goal (in one sentence)?

What are the benefits of achieving this goal? Questions What do I want to accomplish? Specific

Why do I want to accomplish this? What are the requirements? What are the constraints? How will I measure my progress?

Measurable

Attainable

How will I know when I’ve accomplished my goal? How can the goal be accomplished? What logical steps should I take? Is this a worthwhile goal? Is this the right time?

Relevant

Do I have the necessary resources to accomplish this goal? Is this goal in line with my longterm objectives?

Timely 226

How long will it take to accomplish this goal?

Goal

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When is the completion of this goal due? When am I going to work on this goal?

Action Plan What specific steps must you take to achieve your goal? Task to complete

Expected completion date

Date actually completed

Obstacles/Challenges What obstacles stand in the way of you achieving your goal? Obstacle

How will you address the challenges if/when they arise?

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Accountability When working toward achieving a goal, it is helpful to have one or two people you agree to check in with regularly. Keeping others informed on your progress can be a useful external motivator. Who can you share your goal with? Talk with one or two individuals who will want to see you achieve your goal. Explain to them why achieving this goal is essential to you. Ask if they’ll support you and hold you accountable in reaching your goal. Select and agree upon future dates/times you will report updates on your progress. Person

228

Frequency of status check-ins

Method of communication

Building Your Action Plan

Goal 4 What is your goal (in one sentence)?

What are the benefits of achieving this goal? Questions

Goal

What do I want to accomplish? Specific

Why do I want to accomplish this? What are the requirements? What are the constraints? How will I measure my progress?

Measurable

Attainable

How will I know when I’ve accomplished my goal? How can the goal be accomplished? What logical steps should I take? Is this a worthwhile goal? Is this the right time?

Relevant

Do I have the necessary resources to accomplish this goal? Is this goal in line with my longterm objectives?

Timely

How long will it take to accomplish this goal? 229

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When is the completion of this goal due? When am I going to work on this goal?

Action Plan What specific steps must you take to achieve your goal? Task to complete

Expected completion date

Date actually completed

Obstacles/Challenges What obstacles stand in the way of you achieving your goal? Obstacle

230

How will you address the challenges if/when they arise?

Building Your Action Plan

Accountability When working toward achieving a goal, it is helpful to have one or two people you agree to check in with regularly. Keeping others informed on your progress can be a useful external motivator. Who can you share your goal with? Talk with one or two individuals who will want to see you achieve your goal. Explain to them why achieving this goal is essential to you. Ask if they’ll support you and hold you accountable in reaching your goal. Select and agree upon future dates/times you will report updates on your progress. Person

Frequency of status check-ins

Method of communication

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Goal 5 What is your goal (in one sentence)?

What are the benefits of achieving this goal? Questions What do I want to accomplish? Specific

Why do I want to accomplish this? What are the requirements? What are the constraints? How will I measure my progress?

Measurable

Attainable

How will I know when I’ve accomplished my goal? How can the goal be accomplished? What logical steps should I take? Is this a worthwhile goal? Is this the right time?

Relevant

Do I have the necessary resources to accomplish this goal? Is this goal in line with my longterm objectives?

Timely 232

How long will it take to accomplish this goal?

Goal

Building Your Action Plan

When is the completion of this goal due? When am I going to work on this goal?

Action Plan What specific steps must you take to achieve your goal? Task to complete

Expected completion date

Date actually completed

Obstacles/Challenges What obstacles stand in the way of you achieving your goal? Obstacle

How will you address the challenges if/when they arise?

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Accountability When working toward achieving a goal, it is helpful to have one or two people you agree to check in with regularly. Keeping others informed on your progress can be a useful external motivator. Who can you share your goal with? Talk with one or two individuals who will want to see you achieve your goal. Explain to them why achieving this goal is essential to you. Ask if they’ll support you and hold you accountable in reaching your goal. Select and agree upon future dates/times you will report updates on your progress. Person

234

Frequency of status check-ins

Method of communication

Building Your Action Plan

Goal 6 What is your goal (in one sentence)?

What are the benefits of achieving this goal? Questions

Goal

What do I want to accomplish? Specific

Why do I want to accomplish this? What are the requirements? What are the constraints? How will I measure my progress?

Measurable

Attainable

How will I know when I’ve accomplished my goal? How can the goal be accomplished? What logical steps should I take? Is this a worthwhile goal? Is this the right time?

Relevant

Do I have the necessary resources to accomplish this goal? Is this goal in line with my longterm objectives?

Timely

How long will it take to accomplish this goal? 235

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When is the completion of this goal due? When am I going to work on this goal?

Action Plan What specific steps must you take to achieve your goal? Task to complete

Expected completion date

Date actually completed

Obstacles/Challenges What obstacles stand in the way of you achieving your goal? Obstacle

236

How will you address the challenges if/when they arise?

Building Your Action Plan

Accountability When working toward achieving a goal, it is helpful to have one or two people you agree to check in with regularly. Keeping others informed on your progress can be a useful external motivator. Who can you share your goal with? Talk with one or two individuals who will want to see you achieve your goal. Explain to them why achieving this goal is essential to you. Ask if they’ll support you and hold you accountable in reaching your goal. Select and agree upon future dates/times you will report updates on your progress. Person

Frequency of status check-ins

Method of communication

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Workbook Exercise 3-4: Build your wellness recovery action plan Goal Mary Ellen Copeland describes this approach in her book Wellness Recovery Action Plan. WRAP is a self-management and recovery system developed by a group of people with mental health difficulties who were struggling to incorporate wellness tools and strategies into their lives. WRAP accomplishes the following: •

Decreases and prevents intrusive or troubling feelings and behaviors

•

Increases personal empowerment

•

Improves the quality of your life

•

Assists you in achieving your own life goals and dreams

When you start working on your WRAP, think about these ideas:

238

•

What are some of the things you feel and do when you’re feeling well?

•

What are your likes and dislikes?

•

What things can you do that may help you feel better?

•

What do others notice about you when you’re well?

•

What are some of your strengths?

Building Your Action Plan

Take your time putting together your WRAP. Daily Maintenance Lists You may have discovered certain things you need to do every day to maintain your wellness. This plan helps you recognize the things you need to do to remain healthy and plan your days accordingly. When you start to feel out of sorts, you can often trace it back to not doing something on your daily maintenance list. Check all the descriptions in the table below that apply to you when you’re feeling in a good place with yourself. Try to check in with yourself daily and complete this exercise again tomorrow. Description of You

Agree

Description of You

Agree

Description of You

Agree

bright

❑

responsible

❑

quiet

❑

cheerful

❑

competent

❑

introverted

❑

talkative

❑

capable

❑

withdrawn

❑

outgoing

❑

industrious

❑

reserved

❑

a chatterbox

❑

curious

❑

retiring

❑

active

❑

supportive

❑

breathe easily

❑

energetic

❑

easy to get along with

❑

enthusiastic

❑

humorous

❑

clear-minded

❑

friendly

❑

a jokester

❑

playful

❑

compassionate

❑

happy

❑

satisfied

❑

fun to be with

❑

enjoy crowds

❑

compulsive

❑

supportive

❑

dramatic

❑

impulsive

❑

creative

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Description of You

Agree

Description of You

Agree

Description of You

Agree

flamboyant

❑

a fast learner

❑

efficient

❑

athletic

❑

content

❑

patient

❑

optimistic

❑

peaceful

❑

organized

❑

reasonable

❑

calm

❑

disciplined

❑

Identify all the things I need to do for myself every day and add your own to the list. Try to check in with yourself daily and complete this exercise again tomorrow. Actions

Add to my list for today

Actions

Add to my list for today

Eat three healthy meals.

❑

Check in with myself to see how I’m doing emotionally.

❑

Drink at least five glasses of water.

❑

Go to work if it is on my schedule for today.

❑

Minimize caffeine consumption.

❑

Look in the mirror and say five positive things to myself.

❑

Minimize sugar consumption.

❑

Appreciate myself.

❑

Minimize junk food consumption.

❑

Give and get a hug from someone.

❑

Minimize alcohol consumption.

❑

Listen to and support someone else.

❑

Minimize nicotine consumption.

❑

Get at least seven hours of sleep.

❑

Exercise for at least 30 minutes.

❑

Wash, iron, and organize my clothes for the next day.

❑

Get exposure to outdoor light for at least 30 minutes.

❑

Read something I enjoy, such as a book, magazine, comic, or website.

❑

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Building Your Action Plan

Actions

Add to my list for today

Actions

Add to my list for today

Take my medications.

❑

Use my mind to do something I find mentally challenging.

❑

Give myself at least 20 minutes of relaxation or meditation.

❑

Listen to some music I enjoy.

❑

Write in my journal for at least 15 minutes.

❑

Connect with someone I haven’t reached out to for a while.

❑

Spend at least 30 minutes enjoying a fun, affirming, or creative activity.

❑

Make a to-do list.

❑

Get support from someone I can be real with.

❑

Make some time for a break during my workday.

❑

Check in with my partner, family member, or close friend for at least 10 minutes.

❑

Read something comforting and pleasant before I go to bed.

❑

Check in with myself to see how I’m doing physically.

❑

Refrain from stimulating activates for at least 60 minutes before I want to go to bed.

❑

Add a few of your own below.

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

Identify all the things I might need to do for myself that would be good to do and add your own to the list. Try to check in with yourself occasionally and return to this exercise when you’re looking for some fresh ideas.

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Actions

Add to my list

Actions

Add to my list

Get a massage.

❑

Play video games

❑

Spend time with my pet.

❑

Shoot some hoops.

❑

Get more sleep.

❑

Take a class.

❑

Buy groceries.

❑

Be in touch with your family and friends.

❑

Do the laundry.

❑

Take some personal time and enjoy your own company.

❑

Write to someone I want to connect with an email or letter.

❑

Take a relaxing bath or shower.

❑

Reply to and send emails before the next day.

❑

Go out for dinner with a friend.

❑

Plan a vacation.

❑

Spend time with a good friend.

❑

Call my sponsor, if I’m in a 12-step program.

❑

Spend extra time with my partner or family member.

❑

Go dancing.

❑

Spend some time with my therapist, case manager, or psychiatrist.

❑

Do some housework.

❑

Plan something fun for the weekend.

❑

Go to a movie or watch a TV show I enjoy.

❑

Plan something fun for this evening.

❑

Work in my yard or on my balcony.

❑

Remember someone’s birthday or anniversary.

❑

Spend time with my pet or a friend’s pet.

❑

Go for a walk or do an outdoor activity for an extended period (gardening, fishing, softball, baseball).

❑

Get a haircut, if you need one.

❑

Do something for someone without them knowing and surprise them.

❑

Go for a walk or hike.

❑

Go on a date with your partner.

❑

Ride your bike or go rollerblading.

❑

Practice relaxation exercises.

❑

Wash your car, bike, scooter, or

❑

Cook and invite someone over for

❑

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Building Your Action Plan

Actions

Add to my list

motorbike.

Actions

Add to my list

dinner.

Call a friend.

❑

Shop for a greeting card for someone you love.

❑

Do some volunteer work.

❑

Get lost in a good book.

❑

Add a few of your own below.

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

Trigger Identification List Identify all the things that, if they happen, might cause an increase in my symptoms and add your own to the list. Triggers

Applies to Me Today

Triggers

Applies to Me Today

Anniversary dates

❑

Being in contact with someone you feel uncomfortable being around

❑

Work stress

❑

Losing a feeling of control

❑

Excessive stress

❑

Feeling out of control

❑

Relationship ending

❑

Disagreement with someone

❑

Spending too much time alone

❑

Feeling cheated

❑

Holidays

❑

Experiencing an injustice

❑

Family get-togethers

❑

Being judged by someone for your issues

❑

Being judged or criticized

❑

Not feeling heard or validated

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Triggers

Applies to Me Today

Triggers

Applies to Me Today

Being teased or put down

❑

Fighting with someone

❑

Being overtired

❑

A hateful outburst from someone

❑

Being left out

❑

Intimacy

❑

Self-blame

❑

Overextending myself

❑

Physical illness

❑

Not enough time alone

❑

Financial problems

❑

Family friction

❑

Sexual harassment

❑

Crowded places

❑

Sexual assault

❑

Sleep disruption or deprivation

❑

Being around an abuser or someone who reminds me of a past abuser

❑

TV show or movie that reminds you of a traumatic event

❑

Drinking alcohol or using street drugs

❑

An unexpected bill

❑

Extreme guilt from saying no to someone

❑

Legal issues

❑

Intense guilt from pushing back when someone does something to you that you don’t want them to do

❑

Rent increase

❑

Seeing a person related to a traumatic experience

❑

Witnessing cruelty to people or animals

❑

Thoughts and emotions that take you back to how you felt during a traumatic experience

❑

The taste of something, such as alcohol, that reminds you of a traumatic event

❑

A sound that reminds you of a traumatic experience

❑

A sensation of pain

❑

A smell that reminds you of a traumatic experience

❑

Reading or hearing words that remind you of something painful

❑

Feeling trapped in a confined space

❑

Returning to the scene of a trauma

❑

Add a few of your own below.

Add a few of your own below.

❑ 244

❑

Building Your Action Plan

Triggers

Applies to Me Today

Triggers

Applies to Me Today

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

Trigger Action Plan Triggers are external events or circumstances that may make you feel like you’re becoming unwell. These are normal reactions to life events, but if you don't respond to them, they’ll feel worse. Being aware of triggering events will increase your ability to cope with them and reduce the possibility they will develop into more severe symptoms. Identify all the things that I can do if I’m triggered to help me reduce severe symptoms and add your own to the list. Actions

Applies to Me Today

Actions

Applies to Me Today

Walk my dog

❑

Get validation from someone I feel close to

❑

Distract myself

❑

Talk to my therapist, case manager, psychiatrist, support professional

❑

Get validation

❑

Go to the library and read

❑

Meditate

❑

Go to a special place in my home where I can relax and feel safe

❑

Do a relaxation exercise

❑

Permit myself to leave work early

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Actions

Applies to Me Today

Actions

Applies to Me Today

Play a musical instrument

❑

Take the day off work

❑

Sing or dance

❑

Take a couple of hours during my day to do a few fun errands

❑

Listen to relaxing music

❑

Take inventory of all the gifts I have in my life

❑

Exercise, go running, go swimming, go to the gym

❑

Make a plan

❑

Clean my kitchen

❑

Socialize with supportive people

❑

Focus on something else

❑

Reflect on how I’m feeling and what I’m thinking

❑

Do something artistic

❑

Go to my support group

❑

Make sure I do everything on my daily maintenance program

❑

Do some deep breathing exercises

❑

Call a support person and ask them to listen while you talk through the situation

❑

Work on changing negative thoughts to positive ones

❑

Add a few of your own below.

Notes

246

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

Building Your Action Plan

Trigger Early Warning Signs Trigger early warning signs are subtle thoughts, feelings, sensations, and behaviors that you tend to experience when you’re first starting to have a problem. These may or may not be related to specific situations. It may be helpful to ask your friends, family, or support professionals for early warning signs they have noticed. Identify all the early warning signs that let me know I may become triggered and add your own to the list. Symptoms

Applies to Me Today

Symptoms

Applies to Me Today

Anxiety

❑

Avoiding others

❑

Nervousness

❑

Isolating myself

❑

Forgetfulness

❑

Being obsessed with something that doesn’t matter

❑

Increased irritability

❑

The start of irrational thoughts

❑

Increased negativity

❑

Spending money on unneeded items

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Symptoms

Applies to Me Today

Symptoms

Applies to Me Today

Not keeping appointments

❑

Poor physical coordination

❑

Being uncaring

❑

Aches and pains

❑

Lack of motivation

❑

Headache

❑

Impulsiveness

❑

Backache

❑

Muscle cramping

❑

Feeling discouraged

❑

Inability to experience pleasure

❑

Feeling hopeless

❑

Feeling slowed down

❑

Changes to eating patterns (increase or decrease)

❑

Feeling speeded up

❑

Changes to sleeping patterns (increase or decrease)

❑

Avoiding doing things on my daily maintenance list

❑

Feeling workless or inadequate

❑

Inattention to personal grooming

❑

Thoughts of hurting myself

❑

Increased checking behavior

❑

Not wanting to get out of bed

❑

Passing exits on the highway or missing turns while driving

❑

Hyperactivity, can’t sit still

❑

Feeling overwhelmed

❑

Recycling bin or garbage is overflowing

❑

House is getting more cluttered

❑

Can’t find things

❑

Forgetting where I put things

❑

Less interest in my appearance

❑

Plants are dying from neglect

❑

Less concern about caring for pets

❑

Forgetting to take medication

❑

Putting things off and procrastinating

❑

Taking the wrong amount of medication

❑

Suppressing grief

❑

Getting angry easily

❑

Suppressing anger

❑

Overreacting to small annoyances

❑

Worrying about things I cannot

❑

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Building Your Action Plan

Symptoms

Applies to Me Today

Symptoms

Applies to Me Today

control Add a few of your own below.

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

Things I Must Do When I Experience Trigger Early Warning Signs Identify all the things I must do when I experience trigger early warning signs and add your own to the list. Actions

Applies to Me Today

Actions

Applies to Me Today

Do the things on my daily maintenance list, even if I don’t feel like doing them?

❑

Tell my therapist, case manager, psychiatrist, or support professional how I’m feeling.

❑

Ask your therapist, case manager, psychiatrist, or support professional for advice.

❑

Ask my therapist, case manager, psychiatrist, or support professional to help me figure out how to take the actions I need to take.

❑

Do at least one relaxation exercise each day for at least 10 minutes.

❑

Write in my journal for at least 15 minutes each day.

❑

Spend at least one hour doing an activity I enjoy each day.

❑

Ask someone to help take over my household responsibilities for a day.

❑

Go to ___ 12-step meetings each week.

❑

Go to ____ support meetings each

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Actions

Applies to Me Today

Actions

Applies to Me Today

week. Remove any dangerous items from my house if I feel like I can’t trust myself.

❑

Give my car keys to someone if I’m worried about dangerous driving.

❑

Ask someone to stay with me for a short period.

❑

Go to stay with someone for a short period.

❑

Refrain from alcohol consumption.

❑

Refrain from caffeine consumption.

❑

Forgive myself.

❑

Give myself permission to have problems and not be perfect.

❑

Use positive self-talk.

❑

Play with my pets or a friend’s pets.

❑

Add a few of your own below.

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

Signs Things are Breaking Down or Getting Worse Identify all the signs or symptoms that indicate that things are getting worse and add your own to the list. Symptoms

Applies to Me Today

Symptoms

Applies to Me Today

Unable to sleep

❑

Hearing voices

❑

Sleeping too much

❑

Chain smoking

❑

Avoiding eating

❑

Paranoia

❑

Wanting to be alone

❑

Unable to complete projects

❑

250

Building Your Action Plan

Symptoms

Applies to Me Today

Symptoms

Applies to Me Today

Racing thoughts

❑

Can’t begin projects

❑

Substance abuse

❑

Seeing things that others don’t see

❑

Inability to slow down

❑

Feeling very oversensitive and fragile

❑

Noticing myself doing bizarre things

❑

Irrational responses to events and the actions of others

❑

Sitting and staring for long periods

❑

Risk-taking behaviors like driving too fast, promiscuity, or dangerous activities

❑

Not caring anymore

❑

Thoughts of self-harm

❑

Stop taking my prescribed medications

❑

Suicidal thoughts

❑

Feeling like I’m crawling out of my skin

❑

Spending excessive amounts of money

❑

Not being aware of my surroundings

❑

Feeling overwhelmed

❑

Severe panic attacks

❑

Crying all day

❑

Obsessed with negative thoughts

❑

Angry or violent outbursts

❑

Add a few of your own below.

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

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Notes

Action Plan for When Things Are Breaking Down or Getting Worse At some point, you may begin to notice your symptoms are becoming worse and you’re feeling very uncomfortable or unwell. These symptoms are signs that you may be in danger, and your symptoms have become severe or dangerous. You are still able to take some action on your behalf, but it is necessary to take immediate, assertive action to prevent a crisis. Identify all the things I can do to help reduce my symptoms 252

Building Your Action Plan

when they become severe and add your own to the list. Actions

Applies to Me Today

Call a crisis hotline in my area.

❑

Call and talk as long as I need to people in my life who are my supporters.

❑

Make sure I’m doing everything on my daily maintenance list.

❑

Call my psychiatrist, caseworker, or support professional to let them know I’m having difficulties and follow their instructions

❑

Arrange to take some time away from any responsibilities.

❑

Write in my journal for at least 30 minutes

❑

Add a few of your own below.

Actions

Applies to Me Today

Take actions so I cannot hurt myself if my symptoms get worse: • Give medications to someone and have them monitor and administer my usage. • Give my car keys to someone I trust for safekeeping. Remove all dangerous items from my home and have a friend or family member keep them safe for me. Arrange for someone to stay with me around the clock until my symptoms subside. Have someone call me to check in a few times each day.

❑ ❑ ❑ ❑

❑

❑

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

❑

Crisis Plan: Symptoms That Indicate Others Need to Take Over My Care In spite of your best planning and assertive action, you may find yourself in a crisis where others will need to take over responsibility for your care. You may feel as if you’re spiraling 253

Recovering from Workplace PTSD Workbook

out of control. Identify all the symptoms that indicate that others need to take over full-time responsibility for my care and make decisions on my behalf. Add your own to the list. Symptom

Applies to Me Today

Symptom

Applies to Me Today

Not sleeping at all

❑

Criminal activities

❑

Not getting out of bed at all

❑

Refusing to eat or drink

❑

Neglecting personal hygiene

❑

Not leaving the house at all

❑

Not taking care of my pets

❑

Screaming at voices

❑

Destruction of property

❑

Giving things away

❑

Self-destructive behavior

❑

Staying in the same clothes all the time

❑

Uncontrollable pacing, unable to remain still

❑

Thinking that someone is trying to hurt me or spy on me

❑

Not cooking or doing any housework

❑

Thinking I’m someone I’m not

❑

Thinking I can do something I can’t

❑

Planning suicide or rehearsing suicide

❑

Throwing things away for no reason

❑

Not showing up for work and not contacting anybody to let them know

❑

Inability to stop compulsive behaviors like always counting things

❑

Uncontrollable thoughts of hurting myself

❑

Add a few of your own below.

254

Add a few of your own below.

❑

❑

❑

❑

❑

❑

❑

❑

Building Your Action Plan

Notes

255

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Crisis Plan: People to Take Over My Care I want the following people to take over for me when my symptoms become severe and I’m unable to take care of myself. Person’s Name

Connection, Role, or Relationship to Me

Phone Number

Email

If there are disputes between my supporters, this is how I would like the situation handled.

256

Building Your Action Plan

Crisis Plan: People I Do Not Want to Be Involved These individuals must not be contacted and should not be involved in my care or treatment. Person’s Name

Connection, Role, or Relationship to Me

Reason for No Involvement

Notes

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Crisis Plan: Medications These medications would be acceptable to me if medications became necessary. Name of the Medication

Notes

258

Dosage

Reason for Medication

Building Your Action Plan

These medications must be avoided. Name of the Medication

Dosage

Reason to Avoid Medication

Notes

259

Recovering from Workplace PTSD Workbook

Crisis Plan: Treatments These treatments may help reduce my symptoms. Treatments that may help me

When these treatments should be used

I want these treatments to be avoided. Treatments to avoid

260

Why these treatments should be avoided

Building Your Action Plan

Workbook Exercise 3-5: How I would like support to be delivered Goal Start researching support options by deciding how you want your support to be delivered. Keep in mind your personal situation when making this choice. Instructions •

Pick a delivery method you can feel comfortable with.

•

Consider the issues you’ve identified through your recovery discovery process so far.

•

The decision grid below may be helpful if you’re unsure about the right delivery method for your situation and recovery needs.

A Good Option Under These Circumstances

Avoid Under These Circumstances

Individual Counseling

If you feel it is best to work through your issues one-on-one.

Individual counseling is a good option in all situations where you need support.

Couples Counseling

If you have a partner who is willing to work with you and go to counselling with you.

If your partner is abusing you physically, sexually, or psychologically.

If your interactions with my partner impact your issues.

If your partner is unwilling to work together with you. Consider individual counseling or group counseling as an alternative.

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Family Counseling

A Good Option Under These Circumstances

Avoid Under These Circumstances

If you have a supportive family that encourages your recovery.

If there is violence, sexual abuse, or psychological abuse, it is recommended to start with individual counseling to strengthen your psychological resources first.

If your issues would be helped by involving your family. If you’re finding it difficult to get help, and family support would ensure you get the help you need. Group Counseling

If you’re on a limited budget and still want to receive support, group counseling is a great option. If social support and meet people who have been through a similar experience would ease your suffering and help you.

Consider individual counseling or group counseling as an alternative.

If your issues are difficult for you to open up about, and you’re afraid or embarrassed to discuss them in a group setting. Consider individual counseling as alternatives.

Enter your support delivery preference in the table below along with any notes to help remind you of the reasons for selecting this support delivery approach. How support is delivered 1.

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Individual Support

Preferred Notes

❑

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How support is delivered

Preferred Notes

2.

Couples Support

❑

3.

Family Support

❑

4.

Group Support

❑

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Workbook Exercise 3-6: Researching my preferred recovery resources This exercise may be useful if you’re not yet working with a support professional and need to develop a plan to find someone. Goal Make decisions about the type of professional you’d prefer to work with. Instructions

264

•

Refer back to the descriptions of the different types of recovery professionals earlier in this section.

•

Select the options that align with your preferences in the table below.

•

Write a few notes, while your thoughts are fresh in your mind, to remind you what support you might need from those professionals.

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Type of Professional

Sub-Category

I see a fit

What support would I need from this professional?

❑

1.

Career Counselor

2.

Life Coach

Relationships

❑

3.

Life Coach

Life Transitions

❑

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Type of Professional

Sub-Category

I see a fit

4.

Life Coach

Self-Discovery

❑

5.

Life Coach

Health and Wellness

❑

6.

Life Coach

Creativity

❑

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What support would I need from this professional?

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Type of Professional

Sub-Category

I see a fit

7.

Social Worker

Child, Family, and School Social Worker

❑

8.

Social Worker

Medical and Public Health Social Worker

❑

9.

Social Worker

Mental Health and Substance Abuse Social Worker

❑

What support would I need from this professional?

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Type of Professional

Sub-Category

I see a fit

10.

Psychologist

School Psychologists

❑

11.

Psychologist

Psychologists in Private Practice

❑

12.

Psychologist

Hospital Psychologists

❑

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What support would I need from this professional?

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Type of Professional

Sub-Category

I see a fit

13.

Psychologist

Clinical Psychologists

❑

14.

Psychologist

Educational Psychologists

❑

15.

Psychologist

Neuropsychologists

❑

What support would I need from this professional?

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Type of Professional

Sub-Category

I see a fit

16.

Psychologist

Social Psychologists

❑

17.

Psychologist

Occupational Psychologists

❑

18.

Psychologist

Sexologists

❑

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What support would I need from this professional?

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Type of Professional 19.

Sub-Category

I see a fit

What support would I need from this professional?

❑

Psychiatrist

Workbook Exercise 3-7: Selecting three local professional support resources Goal Make some decisions about which local recovery resources you’d like to contact to schedule an initial consultation. Instructions •

Earlier in this section, I walked you through strategies for researching local professional support resources.

•

Review the steps and suggestions earlier in this section and make a list of up to three professionals.

•

Rank them in order of preference.

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Preference After you’ve completed your research, select the professionals you want to contact. Type of Professional

Contact Number or Email Address

Name

1.

2.

3.

Workbook Exercise 3-8: Reaching out and scheduling an initial consultation Goal Contact the top three preferred support professionals, ask some screening questions, and if you’re comfortable, schedule an initial consultation. Instructions

272

•

Return to the top three preferred support professionals you’ve decided to contact.

•

Contact them using your preferred method of communication.

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•

If you find it challenging to call someone you don’t know, sending an email can be a great alternative if you have time to wait for a reply before getting support.

•

Before you contact them, write down a few notes so you have an outline of what you would like to communicate, and to clarify your thoughts.

•

If you need urgent help, visit the nearest emergency department or call your local emergency phone number for assistance.

A Few Useful Questions to Ask The National Alliance on Mental Illness (NAMI, www.nami.org) and the Canadian Mental Health Association (cmha.ca) both offer a wealth of useful information. I recommend visiting the website for more helpful tips. Here are some of the questions NAMI recommends asking when you initially contact a support professional: •

Do you feel comfortable with this person?

•

Even if this person has a good reputation or a high level of education, the most important thing is whether you can work well together.

•

What “vibe” do you get?

•

The personal questions a mental health professional asks may make you uncomfortable sometimes, but the person shouldn’t make you uncomfortable.

•

You should feel that this person is on your side.

•

How much education and professional experience does this person have? 273

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•

Has this person worked with people similar to me? For how long?

•

Is there a fee for the initial consultation? Alternatively, is the initial meeting free of charge?

•

How will you work together to establish goals and evaluate your progress?

•

What can you expect if you work together?

•

How often will you meet and how hard will it be to get an appointment?

•

Can you call on the phone or email between appointments?

•

What kind of improvements can you expect to see?

•

If you’re concerned about your ability to meet insurance co-pays or deductibles, bring it up now rather than later.

•

Ask if you can pay on a sliding scale or at a discount.

•

Doctors and therapists would like to know ahead of time if these problems might arise because it's essential to continue treatment without interruption.

•

If having a provider who understands and respects your cultural background is essential to you.

Schedule an Initial Consultation, If You Feel Comfortable Scheduling your first consultation with your preferred support professionals takes some effort; however, it is worth the time and effort. It’s typical to experience a feeling of relief, knowing you have advocated for yourself and are beginning your recovery journey. Many support professionals offer online scheduling tools, which 274

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can be a great way to see their availability and schedule an appointment that fits your schedule and availability. Here are a few things to keep in mind when scheduling an appointment: •

Take note of the cancelation or rescheduling policies. Many professionals will charge you for the appointment if you don’t provide sufficient notice before canceling or rescheduling.

•

It is always worth asking about the ability to manage your appointments online.

•

This makes it very convenient and easy to do.

•

This easy method of managing appointments is particularly essential when you’re depressed or anxious because every task can feel like it takes much effort to complete.

•

Schedule enough travel time to avoid the stress of being late. You’ll need a bit of extra time to fill out forms before the appointment.

•

I always visit an online map website to get a rough idea of the travel time to their office.

•

Mapping websites typically offer the ability to calculate travel times for walking, driving, biking, or taking transit.

•

Give yourself an extra 20–30 minutes, so you have less stressful travel experience.

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Appointment Details Name

Date

Time

Location

Notes

PTSD Treatment Options There is no one-size-fits-all approach to PTSD recovery. Feeling supported and understood by a trusted professional will help you heal your pain and move toward a happier and more fulfilled life. Several treatments can help reduce and treat the distressing symptoms associated with trauma. The effectiveness of these treatments depends on the severity of your symptoms, 276

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your coping skills, and how much social support you have. PTSD treatments have three goals: 1. Teach you skills to manage your symptoms. 2. Improve, reduce, or eliminate your symptoms. 3. Restore your self-esteem.

Medications The brains of people with PTSD process “threats” differently, in part because trauma disrupts the delicate balance of chemicals in the brain called neurotransmitters. Three major classes of medications are used to treat the anxiety symptoms of PTSD: 1. Selective serotonin reuptake inhibitors (SSRIs) 2. Serotonin-norepinephrine reuptake inhibitors (SNRIs) 3. Tricyclic antidepressants (TCAs) The neurotransmitter serotonin plays a central role in the experience of mood and anxiety. Selective serotonin reuptake inhibitors are used to adjust the balance of serotonin in the brain. They relieve PTSD symptoms by blocking the reabsorption, or reuptake, of serotonin by specific nerve cells in the brain, leaving more serotonin available, which improves mood. Common side effects of SSRIs include insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for anxiety and can help people experiencing OCD. SSRIs are typically the first class of medications used to treat PTSD (Brady et al., 2000; Marshall, Beebe, Oldham, & Zaninelli, 2001). 277

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Serotonin-norepinephrine reuptake inhibitors, in comparison, increase levels of two neurotransmitters (serotonin and norepinephrine) by inhibiting their reabsorption into brain cells. Common side effects of SNRIs include stomach upset, insomnia, headache, sexual dysfunction, weight gain, and a minor increase in blood pressure. These medications are considered as effective as SSRIs for the treatment of anxiety, but they aren’t effective in treating OCD. Concerns about long-term use of SSRIs and SNRIs have led doctors to favor a class of drugs called tricyclic antidepressants. TCAs are an effective treatment of some forms of anxiety but have some significant side effects, including orthostatic hypotension (a drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.

Cognitive-Behavioral Therapy Most PTSD therapies fall under the umbrella of cognitive behavioral therapy (CBT). CBT has consistently been found to be the most effective treatment of PTSD in both the short and long term. Its objective is to change your disruptive thought patterns by focusing on identifying, understanding, and improving your thinking and behavior patterns. Its structured psychotherapeutic approach will help you identify the events, situations, or objects that trigger your PTSD symptoms. You will learn how to change any negative thinking, address painful feelings of guilt, shame, and blame, and develop effective relaxation and coping skills to help you manage your PTSD symptoms. 278

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This active treatment approach involves talking about your trauma and concentrating on the origin of your fears. It engages the PTSD survivor both within and outside weekly appointments; the skills learned during therapy sessions are practiced repeatedly and help support symptom improvement. CBT treatments typically take place over 12–16 weeks. Now I’ll walk you through the different types of CBT used to treat PTSD. Exposure therapy helps PTSD survivors face and control their fears by exposing them to the trauma memory while they’re in a safe environment. Exposure can use mental imagery, writing, or visits to places or people that remind them of the trauma. Eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy that involves processing upsetting trauma-related memories, thoughts, and feelings. EMDR asks PTSD survivors to pay attention to either a sound or a back-andforth movement while thinking about the trauma memory. The treatment focuses on recalling the traumatic experience while watching or listening to something such as moving a hand, flashing light, or a sound. This treatment was found to be useful for treating PTSD, but research has identified exposure to traumatic memories as the therapeutic element of EMDR, not the eye movements (Shapiro, 2014). These two methods of exposure are both designed to expose the PTSD survivor to the trauma gradually so they become less sensitive to it over time. CBT relaxation and cognitive and education techniques are paired with exposure to help the PTSD survivor reduce their unpleasant PTSD symptoms while being exposed to simulations of the original trauma. 279

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Cognitive restructuring treatments help PTSD survivors make sense of traumatic memories, since they often remember their trauma differently from how it originally happened. For example, they may not remember certain parts of the trauma or may recall the events in a disjointed way. It is common for survivors to feel guilt or shame about aspects of the trauma that were not their fault. Cognitive restructuring addresses these traumatic memories by helping PTSD survivors look at the traumatic events more factually and objectively. That process helps PTSD survivors build a more realistic and accurate perspective of their traumatic memories. Cognitive processing therapy (CPT) also applies cognitive therapy to evaluate and change trauma-related thoughts. CPT is typically a 12-week course of treatment, with weekly sessions of 60–90 minutes. Research has found CPT to be effective across many types of PTSD traumas. The process begins with the PTSD survivor talking about the traumatic event and how these thoughts have affected their lives. Then they write a detailed summary of what happened. This process helps the PTSD survivor examine how they think about their trauma and develop new ways of living with it. Inaccurate thoughts following trauma can prevent PTSD survivors from recovering. CPT encourages PTSD survivors to look at why the trauma occurred and the impact it has had on their personal beliefs. CPT focuses on the way people view themselves, others, and the world after experiencing trauma. This approach teaches skills that help survivors evaluate whether facts support their thoughts or if there are more helpful ways to think about the trauma. 280

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PTSD survivors commonly blame themselves for what happened. The CPT therapist helps the survivor take into account all the elements that were beyond their control. This treatment helps them move forward with an understanding that it wasn’t their fault, despite what they did or didn’t do at the time. Prolonged exposure therapy (PE) relies more heavily on behavioral therapy techniques to help PTSD survivors gradually approach trauma-related memories, situations, and emotions. Treatment involves 8 to 15 sessions, usually 90 minutes each. PTSD survivors may avoid reminders of their traumatic experiences, which works well in the short term but prevents full PTSD recovery. PE exposes the PTSD survivor to reminders of their trauma and teaches them to recall details of the traumatic experiences. PE walks the survivor through a process of imagining the traumatic experience and then recounting the details. This mode of treatment also involves confronting trauma-related situations or people in their daily lives that they have been avoiding. The PE therapist teaches breathing techniques to reduce anxiety when the PTSD survivor thinks about what happened. The survivor then creates a list of the things and situations they’ve been avoiding. One by one, the therapist works with the survivor to help them learn how to face them. In other PE therapy sessions, the survivor recounts the traumatic experience while being recorded. A homework exercise is assigned for the PTSD survivor to listen to the recording and practice being exposed to the traumatic memories. Over time this exposure reduces symptoms. 281

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Stress inoculation training (SIT) can be used as a stand-alone treatment or may be combined with other CBT treatments. The goal of SIT is to change how survivors deal with stress. It teaches them to react differently to their symptoms by teaching coping skills such as breathing, muscle relaxation, cognitive restructuring, and assertiveness skills. Treatment typically takes place over three months in a support group or during individual therapy sessions. Present centered therapy (PCT) is a non-trauma-focused treatment that centers on current issues rather than directly processing the trauma. PCT applies psychoeducation to teach PTSD survivors about the impact the trauma has on their lives and educates them about new problem-solving strategies for stress management.

Anxiety Management Anxiety management is a collection of tools and techniques that span psychotherapy, counseling, medications, and lifestyle changes. Telling anxiety-prone clients to take care of their bodies by getting enough sleep, eating right, avoiding alcohol, nicotine, sugar, and caffeine, and exercising is a strikingly ordinary “prescription,” but not doing these things can undermine the effectiveness of other antianxiety techniques. Alcohol and caffeine can aggravate anxiety and trigger panic attacks so cutting back on stimulants can be an effective anxiety management strategy. Skipping meals can increase anxiety symptoms; maintaining a balanced healthy diet maintains blood sugar, boosts energy, and reduces the severity of anxiety 282

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symptoms. Take a look at your sleeping habits and ensure you get enough rest. Your body requires more sleep and rest when stressed. Adding exercise to your weekly routine will boost wellness, makes you feel better, and helps you manage stress more effectively. Deep breathing, mindfulness, and meditation eliminate obsessive thinking, reduce anxiety, and increase optimism through an attitude of gratitude. Medical professionals can prescribe antianxiety medications that can reduce symptoms enough so that the PTSD survivor can more effectively concentrate on their recovery.

Emerging Treatments Drug therapy combined with CBT is the most common method of treating PTSD. Medications lessen the symptoms of anxiety, depression, and racing thoughts, while CBT helps the survivor learn new coping skills and ways of thinking to help manage the symptoms. Researchers continue to explore new ways to treat PTSD, and there are two promising new therapies on the horizon that address some disadvantages of CBT and accelerate recovery in a way that’s gentler on the PTSD survivor. Virtual Reality Exposure Therapy Virtual reality exposure therapy (VRET) relies on virtual reality technology to simulate an environment that resembles the traumatic event. The PTSD survivor is safely exposed to a simulation of the environment that contains the feared situation. 283

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VRET fools your brain by linking the virtual world you see through the display goggles to your head’s movements. Its creators refer to this perception effect as “presence.” No matter how abstract the virtual world is, this brain trickery makes your mind think you’re there. Exposure therapy is an ideal match with virtual reality (VR) because therapists can place PTSD survivors in provocative environments and systematically control the stimulus they receive. Every element of a traumatic memory is recreated in the VR world, from the timing of an explosion to the helicopters flying overhead. Research is investigating if VR therapy is more effective than having patients describe their trauma from memory, which is typical for CBT. The hypothesis is that VR will help people recover faster because of the vividness of the sensory experience. In 1997, a research team led by Albert Rizzo from Georgia Tech in the U.S. was the first to apply the emerging VR technology to create highly realistic virtual environments to use in PTSD exposure therapy. Ten volunteers, Vietnam veterans suffering from PTSD who had not responded to multiple treatments, signed up for the pioneering clinical trial. During the study, called “Virtual Vietnam,” each of the veterans put on a VR headset and was instantly transported to a war zone. The psychotherapist manipulated the sights and sounds in the virtual environment while each patient recalled details of their trauma. After a month’s treatment, all the patients showed significant reductions in PTSD symptoms. The research program evolved after the World Trade Center attacks in 2001. One of Rizzo’s collaborators, JoAnn Difede, 284

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began using VR to treat the 9/11 burn victims who began experiencing PTSD. “People saw the buildings, saw the plane fly into the buildings, heard the sounds, and watched the explosion,” she explains. “We did not know if it would work. It did. Better than I ever expected” (Rizzo et al., 2006; Rizzo et al., 2008). Virtual reality exposure combined with drug therapy is another promising treatment. The drug D-cycloserine, when combined with VRET, accelerates the effectiveness of treatment by acting on glutamate receptors in the brain to enhance learning. The drug, which is administered to the patient undergoing treatment right before VR exposure, has helped patients “relearn” more effectively so they can overcome the automatic stress reaction more quickly. The research program found a 70 percent remission rate within six months (Difede et al., 2014; Baker, Cates, & Luthin, 2017). MDMA-Assisted Psychotherapy The therapeutic effects of another drug, MDMA (commonly known as ecstasy), were anecdotally discovered when recovery benefits were observed by medical professionals treating PTSD for recreational MDMA users. A team of military doctors and psychiatrists noted the benefits of MDMA and found that its use dramatically reduced PTSD symptoms when paired with psychotherapy. MDMA was discovered in 1912 and first used in underground psychotherapy circles during the 1970s. In the 1980s, MDMA spread into rave culture (Global Drug Survey, 2014). It is a derivative of the amphetamine family of stimulants and 285

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increases levels of the neurotransmitters serotonin, dopamine, and norepinephrine in the brain. The subjective effects of MDMA include anxiety suppression, reduced inhibitions, enhanced empathy, increased sociability, feelings of relaxation, and euphoria (World Health Organization, 2004). Today PTSD is nearing epidemic status, especially among veterans of Operations Iraqi Freedom and Enduring Freedom. The U.S. Department of Veterans Affairs estimates between 11 and 20 percent of those veterans suffer from the condition. Doctors and psychiatrists in military mental health clinics have begun exploring if MDMA medication paired with psychotherapy could help curb that glaring trend. Early studies showed that psychotherapy treatment, paired with MDMA, enhances the therapeutic process by reducing fear and defensiveness, enhancing communication, fostering introspection, increasing empathy, and facilitating compassion (Burge, 2017). Twenty-six first responders (the majority of whom were combat veterans), during two day-long psychotherapy sessions, were administered full doses of MDMA. In a follow-up one month after the second therapy session, researchers found that symptoms of PTSD were effectively eliminated in 68 percent of the study’s participants. Further studies showed that MDMA used just two times at monthly intervals could make psychotherapy much more effective and better tolerated (Mithoefer et al., 2018). The continued success of this emerging treatment with supporting research brings the therapy closer to U.S. Food and Drug Administration approval. The hope is that MDMA 286

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treatment can eventually replace less effective treatment methods. The next phase of testing began in 2018 and featured between 200 and 300 participants across 16 testing sites in the U.S., Canada, and Israel. Demonstrating significant efficacy and safety in this round of tests is expected to result in full FDA approval by 2021. Augmenting Treatment with Life Coaching Another emerging treatment for PTSD is to layer life coaching onto ongoing PTSD treatment. Life coaching is a complementary treatment option for PTSD survivors that tackles the practical aspects of maintaining a productive and successful life while undergoing the sometimes-lengthy process of PTSD recovery. Life coaching is a long- or short-term process that helps clients clarify goals, unearth obstacles, and identify problematic behaviors. Coaches aim to motivate, offer emotional support, and create confidence in their clients. Life coaches work collaboratively with their clients to build an action plan that enables them to take control of their lives, take necessary steps, and steer toward their goals. Here are some examples of how life coaches can work with PTSD survivors on their recovery: •

Facilitate the research process associated with finding suitable PTSD support

•

Help PTSD survivors file claims and disability paperwork

•

Work through social workers and local community resources to coordinate social and life issues support 287

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•

Assist PTSD survivors with managing the complexity of their recovery care while working with the psychologists, psychiatrists, nurses, and medical professionals to coordinate treatment

•

Assist PTSD survivors with mental health disability needs to manage their daily life activities

•

Work with PTSD survivors in foster care by enrolling them in school, encouraging them, supporting them in various ways, and mentoring them to achieve life goals successfully

New mobile coaching apps that leverage artificial intelligence are being tested now. The U.S.’s National Center for PTSD released “PTSD Coach,” an app that delivers psychoeducation and self-management tools for trauma survivors with PTSD symptoms. Emerging research on the coaching app demonstrates high user satisfaction, improvement in PTSD symptoms, and positive psychosocial outcomes (Kuhn et al., 2018). The source code is being shared with the military in other NATO countries, and localized versions are being developed in Australia, Canada, the Netherlands, Germany, Sweden, and Denmark. These software coaching tools are particularly helpful in reaching trauma survivors in areas where few or no other mental health resources exist.

Complementary Treatments Bullying, harassment, discrimination, and trauma can severely impact a person’s confidence and happiness. Many people benefit from complementary treatments that help improve their 288

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sense of self-esteem and feeling of well-being. Some complementary therapies have been found to help PTSD survivors rebuild a positive perception of themselves. Wahbeh and colleagues (2014) conducted a scientific review of research investigating complimentary PTSD treatment and found it insufficient for these commentary treatments: •

Biofeedback

•

Emotional freedom and thought field therapies (TFT)

•

Relaxation

•

Yoga breath work

•

Natural products such as herbal and botanical medicines, vitamins, minerals, dietary supplements, probiotics, and fish oil

However, scientific evidence does support the benefits of these complementary PTSD treatments (Wahbeh et al., 2014), ranked from highest to lowest benefit: 1. Repetitive transcranial magnetic stimulation (rTMS) 2. Acupuncture 3. Mindfulness training and meditation 4. Hypnotherapy 5. Visualization 6. Lifestyle changes Repetitive transcranial magnetic stimulation (rTMS) is a painless, non-invasive technique that directly stimulates the brain. It is approved by the U.S. Food and Drug Administration for the treatment of depression (Berlim, Van den Eynde, & 289

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Daskalakis, 2013). rTMS involves sending a series of short magnetic pulses directed to the brain to stimulate nerve cells. These pulses stimulate the neurons that send electrical signals in the brain. This treatment positively changes the functioning of the brain circuits linked to depression (Hollifield, Sinclair-Lian, Warner, & Hammerschlag, 2007; Bryant et al., 2006). Acupuncture is a Chinese medicine that uses fine needles inserted into specific points on the body. It may help PTSD recovery by stimulating the nervous system and areas of the brain associated with PTSD (Hollifield et al., 2007; Berlim et al., 2013). Meditation also appears to help treat PTSD. While there are

various meditation styles, all types incorporate self-observation of mental activity, attention training, and cultivating a heightened awareness of thoughts and feelings. Meditation may affect PTSD symptoms through attention training, improving nervous system functioning, changing thought patterns, increasing emotional acceptance, and reducing avoidance behaviors. Meditation studies show positive benefits for a variety of symptoms linked to PTSD such as depression, anxiety, suicidal behavior, and sleep disturbances. Hypnotherapy, another mind-body medicine, is a

psychotherapeutic technique based on a hypnotist providing suggestions for changes in sensation, perception, cognition, affect, mood, or behavior. Hypnotherapy may allow people with PTSD to down-regulate their autonomic nervous system and become more receptive to changes in cognition, mood, or behavior. 290

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Visualization is explicitly designed for the patient’s imagination

(mind) to affect a physiological system (body). It is a lived experience that is a dynamic, quasi-real, psychophysiological process. Guided imagery is a variation on visualization where one person leads another through experiences in the mind to access the physical, emotional, and spiritual dimensions that affect physiological change, modulating the individual’s response. Both hypnotherapy and visualization/guided imagery could be modified to address the specific symptoms the person with PTSD is experiencing. Lifestyle changes have been found to benefit PTSD survivors (Webber, Mascari, Dubi, & Gentry, 2005). Here are some of the most useful lifestyle changes: •

Aerobic exercise and fitness

•

Finding meaningful relationships

•

Living in a safe and supportive environment

Preferred Treatments The following is a summary of the most effective treatments for each PTSD symptom (Foa, Davidson, & Frances, 1999; Baker et al., 2017). Most Prominent Symptom

Recommended Techniques

Other Treatments to Consider

Intrusive thoughts

Exposure therapy

Cognitive behavioral therapy Anxiety management Present centered therapy

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Most Prominent Symptom

Recommended Techniques

Other Treatments to Consider

Flashbacks

Exposure therapy

Anxiety management

Virtual reality exposure therapy

Cognitive behavioral therapy MDMA-assisted psychotherapy Present centered therapy

Trauma-related fear, panic, and avoidance

Exposure therapy

Present centered therapy

Virtual reality exposure therapy

MDMA-assisted psychotherapy

Cognitive behavioral therapy Anxiety management Numbing, detachment from others, loss of interest

Cognitive behavioral therapy

Present centered therapy Exposure therapy

Irritability, angry outbursts

Cognitive behavioral therapy

Present centered therapy

Anxiety management

Exposure therapy

Guilt, shame

Cognitive behavioral therapy

Present centered therapy

General anxiety, hyperarousal, hypervigilance, being easily startled

Anxiety management

Cognitive behavioral therapy

Exposure therapy

MDMA-assisted psychotherapy

Sleep disturbance

Anxiety management

Virtual reality exposure therapy

Present centered therapy

Exposure therapy Cognitive behavioral therapy Present centered therapy

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Most Prominent Symptom

Recommended Techniques

Other Treatments to Consider

Difficulty concentrating

Anxiety management

Cognitive behavioral therapy Psychoeducation

Difficulty managing daily life

Present centered therapy

Anxiety management

Augmenting treatment with life coaching

Lifestyle changes

Below is a summary of recommended PTSD treatments based on their characteristics (Foa, Davidson, & Frances, 1999; Baker et al., 2017). Characteristics

Recommended Techniques

Other Treatments to Consider

Most effective techniques

Exposure therapy

Anxiety management

Cognitive behavioral therapy

Quickest acting techniques

Exposure behavioral therapy

Anxiety management Cognitive behavioral therapy Present centered therapy

Techniques preferred across all types of trauma

Cognitive therapy

Present centered therapy

Exposure behavioral therapy Anxiety management

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Characteristics

Recommended Techniques

Other Treatments to Consider

Safest techniques

Anxiety management

Exposure therapy

Psychoeducation Cognitive behavioral therapy

Emerging experimental techniques

Augmenting treatment with life coaching MDMA-assisted psychotherapy

Most acceptable techniques

Present centered therapy Cognitive therapy Anxiety management

Complimentary techniques

Repetitive transcranial magnetic stimulation (rTMS)

Popular but not scientifically proven to be effective:

Acupuncture

Biofeedback

Hypnotherapy

Emotional freedom and thought field therapies (TFT)

Mindfulness training and meditation Visualization Lifestyle changes

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Relaxation Yoga breath work

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Synopsis •

A recovery plan is the foundation of an effective path to recovery.

•

PTSD makes it difficult to gain the strength and courage to start the recovery journey; being a self-advocate is a crucial learned skill to help you stand up for yourself and take care of your needs.

•

PTSD treatments strive to teach skills for managing and improving PTSD symptoms by reducing or eliminating them and ultimately restore self-esteem.

•

The following professionals are part of a PTSD recovery team: psychotherapists, career counselors, life coaches, social workers, psychologists, and psychiatrists.

•

The first challenge you’ll face when researching your recovery options is finding a qualified professional with the right experience to help you. Use the steps discussed in this section to start the search.

•

Most PTSD therapies fall under the umbrella of cognitive behavioral therapy (CBT) and focus on changing thought patterns by identifying, understanding, and improving thinking and behavior trends.

•

PTSD survivors process “threats” differently because the delicate balance of chemicals in the brain has been disrupted by trauma. Three classes of medications are used to treat the symptoms of PTSD: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs). 295

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296

•

Many PTSD survivors benefit from complementary treatments that help improve their self-esteem and feeling of well-being.

•

Virtual reality exposure therapy provides a virtual environment that simulates the traumatic event; the PTSD survivor becomes desensitized to the trauma, which reduces PTSD symptoms.

•

The drug MDMA has been found to dramatically reduce PTSD symptoms when paired with psychotherapy.

•

Layering life coaching onto other forms of treatment helps PTSD survivors tackle the practical aspects of maintaining a productive and successful life while undergoing the sometimes-lengthy recovery process.

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Grieving, Mourning, Letting Go, and Moving Forward

SECTION 4: GRIEVING, MOURNING, LETTING GO, AND MOVING FORWARD Introduction As we’ve learned, trauma can be an event such as violence, sexual assault, witnessing death, or abuse that ultimately causes psychological, physical, emotional, or mental harm. A traumatic event can be referred to as a loss event. If someone dies, we’ve lost someone. If someone is abused, there is a loss of trust. Whether you want to call the event a trauma or a loss, the result of a traumatic experience is grief. Trauma reduces the effectiveness of the brain’s stress management system, and this impairs the grieving process. Generally, it takes longer to grieve when the traumatic experience was unexpected. Emotional flashbacks take the PTSD survivor back to a state of fear, humiliation, abandonment, helplessness, and hopelessness. The grieving process help survivors work through the “death-like experience” of feeling lost and trapped in flashbacks and painful memories (Walker, 2011). When PTSD survivors begin the recovery process, they enter a phase of grief and mourning, but as they build a new selfidentity and make sense of what happened, they eventually reach a new place of calm and acceptance.

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Grieving Grief is our natural response and private reaction to loss, and there is nothing unhealthy or problematic about the act of grieving (Worden, 2008). Grief is the feeling of wishing things would have ended differently, better, or less painfully. Mourning is the process we go through to adapt to our loss. Emotional and physical experiences are clues that let us know we’re managing a loss that means something to us. Approximately 40 percent of grieving people will struggle with anxiety in the first year following their loss (American Psychiatric Association, 1980). Grieving people find themselves crying unexpectedly, waking up with headaches, feeling emotionally numb, having trouble sleeping, eating too much or too little, and carrying around a weight of sadness all day. Clues That You’re Grieving These signs will give you a clue that you’re grieving, even if you’re not aware of it. Physical Reactions • • •

Being short of breath Feeling very tired Experiencing restlessness

Emotional Reactions • •

Feelings of shock, fear, anxiety, guilt, and anger Blaming yourself or others for the loss

Mental Reactions • •

Feeling confused Experiencing difficulties making decisions

Social Reactions 300

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• •

Avoiding other people Overreacting or reacting strongly to others

Spiritual Reactions • •

Contemplating why pain and suffering exist Asking the universe why the loss had to happen to you

Kübler-Ross’s five stages—denial, anger, bargaining, depression, and acceptance—are part of a popular framework that describes the process of learning to live with loss (Kübler-Ross, 1969; Kübler-Ross & Kessler, 2005). Think of these stages of grief as a tool to help us frame and identify what we may be feeling. The stages map the terrain of grief, and there is no typical response for any stage. Grieving must run its course; it’s over when we’ve done the work we need to do. There is a general flow to grieving, but it isn’t always linear. People move between the different stages at different rates and can jump around between phases. What will you experience when grieving? • • • •

Your grief will take longer than you think to pass. Your grief will take more energy than you imagined. Your grief will depend on how you perceive your loss. Your grief will entail mourning all the hopes, dreams, and unfulfilled expectations you had.

• • •

Your grief will resurrect old issues, emotions, and unresolved conflicts from the past. Your grief will create some identity confusion and change how you perceive yourself. Your grief will cause you to begin a search for meaning.

• • •

Your grief will lead you to question your faith or philosophy of life. You will grieve the needs that were unmet because of the loss. You will grieve what you have already lost. 301

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• •

You will grieve what will be lost in the future. You will grieve the symbolic and intangible things you have lost.

Source: Rando & Therese (1991)

Some grieving people may not experience every emotional stage, while others linger longer in one of the stages. One person may have intense feelings, and another may deny that any loss has occurred. Most people will find it difficult to recover from loss on their own and engaging with others is a critical element in resolving grief successfully. Without the help of others, many people will express their feelings of loss in inappropriate and misdirected ways. The process of trauma recovery mirrors the grieving process. The first reaction to trauma is disbelief and shock. In some cases, when adults have only just realized they were abused as children, this initial phase can be delayed. What follows are feelings of “frozen fright,” a detached pseudo-calm during which the victim is compliant. It is this appearance of cooperation that’s confused with “consent” when the PTSD survivor looks back on their experience. The next phase of trauma recovery is a delayed but chronic depression combined with periods of apathy, anger, resignation, resentment, rage, insomnia, and the repeated mental replaying of events. The final recovery phase is characterized by resolving the trauma and integrating the experience after going through periods of bargaining and acceptance (Prigerson, et al., 2008).

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Figure 4-1: The Stages of Grief

”Normal” Functioning

Return to Meaningful Life

Shock and Denial

Acceptance

Bargaining

Anger

Depression & Detachment

Denial and Shock

Depression and Detachment

“Nothing happened.”

“Something happened, and it cost me a lot.”

Bargaining

Anger

“Something happened, but….”

“Something bad happened, and I don’t like it!!”

“Why me? Why did this have to happen to me?” Acceptance “Something happened, and I have healed from it.”

Source: Kübler-Ross, 1969 303

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What do you experience when grieving? •

You may become obsessed with what's been lost.

• •

You may need to retell the story, events, and experiences surrounding your loss. You may alternate between periods of seeking the company of others and wanting to be alone. You may find yourself expecting to be able to return to your life before the loss and then realize you’re unable to.

• • • • •

You may experience an empty feeling in your stomach. You may experience loss of appetite or overeating. You may experience difficulty sleeping and have recurring dreams about your loss. You may experience acute feelings of grief that occur suddenly with no warning.

• • •

You may cry at unexpected times. You may feel as though the loss isn't real, and it didn’t happen. You may feel as though you need to take care of the other people who are uncomfortable around you. You may feel anger, guilt, frustration, irritability, annoyance, or intolerance with yourself and others.

• •

You may feel your mood changes over the slightest thing.

Source: Rando & Therese, 1991

Mourning While grief is your internal reaction to loss, mourning is the active, shared expression of that loss in the outside world. When we mourn, we express our grief beyond the boundaries of our personal experience, and grief becomes expressed socially. This sharing of our sadness eventually helps us decrease the intensity of our grief and transform it into a feeling of resolution and understanding. Wolfelt (2016) describes six stages of mourning that will require your attention intermittently over several months. Be patient and compassionate with 304

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yourself while you work through each stage. Stage 1: Acknowledging Your Reality In the first stage of mourning, you must confront the reality that your life has changed and acknowledge that you can never return to your past. You may have lost your job or were forced to resign because life at work became intolerable. It may take several weeks or months to acknowledge the reality of your loss fully. PTSD complicates this stage of mourning because trauma survivors actively suppress and avoid intimate contact with the pain they are experiencing. Trauma survivors automatically push away thoughts of their traumatic experience because they are uncomfortable with reliving it. This makes it challenging for PTSD survivors to begin processing what has happened to them. Support from a trained professional is an essential part of PTSD recovery because survivors can come to terms with their experiences in a safe environment. You know you’ve reached the end of this stage of mourning when you find yourself describing your trauma and loss as if it happened in the past. Stage 2: Embracing Your Pain and Loss The mourning process requires us to acknowledge and interact with our pain. We gradually accept the trauma, loss, and pain by confronting and expressing it in small, manageable pieces rather avoid overloading ourselves with all the hurt at once. When PTSD survivors can access their traumatic memories, they replay both positive and negative scenarios in their minds. This 305

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mental replaying of events and experience is a vital part of mourning because each time you recall the events, you work through them a little bit more. Over time, these remembered events and experiences become consciously accepted. Sometimes you’ll need to distract yourself from the flashbacks and painful memories. At other times you’ll need to create a safe place inside yourself so you can move toward painful memories and process what’s happened. Shifting your internal dialogue to a friendly, compassionate, and loving “inner voice” will make it easier for you to pass through this stage of mourning. You know you’ve reached the end of this stage of mourning when you feel acquainted with your trauma, pain, and loss. Survivors experience a feeling of compassion toward themselves and their experiences. Stage 3: Shifting Your Perspective Remembering and sharing the past makes hoping for the future possible. Looking to the future is possible when we open ourselves to new experiences, embrace what we’ve been through, and accept the past. Positive memories that you honor during this stage may include thoughts of former colleagues, the aspects of the job you enjoyed, and the structure of having a consistent daily routine. There may be painful aspects you must honor, such as the challenges workplace trauma brought to your relationships, the long hours you spent at the office, and the bravery it took to live through those experiences. This stage of mourning is completed when you’ve embraced and accepted the past and find yourself being open to new 306

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experiences. You will move to the next stage of mourning when you begin to consider what you want to do with your life. Stage 4: Developing a New Self-Identity Our personal identity is invested in what we do for a living. Losing a job or experiencing workplace trauma changes how we perceive ourselves. Mourning can leave us feeling like we have lost who we are. In other words, the mourning process breaks down our self-identities and forces us to rebuild them in new ways. The Components of Self-Identity Relational Identity: Relational identity is the component of self-identity that comes from our relationships with others. Mourning transforms the way we see ourselves and the way society defines us. Mourning can rewrite our address book and social calendars; former colleagues no longer reply to our emails, and the distance grows between our friends or family. This shift leaves us feeling like we’ve lost our community and connection with others. For example, when we lose our job, we find ourselves asking questions like, “Who am I if I’m no longer employed?” Professional Identity: Phrases we use to describe ourselves, such as “I’m a teacher" or “I’m a doctor,” make it clear that our profession is an essential aspect of who we are. Our career affirms that we have knowledge, skills, and expertise. When we lose or leave a job, even if it is our choice, our professional identity changes. Work gives us structure and purpose, and when we no longer have that job, our professional identity must adjust to that new reality. Financial Identity: Our ability to financially provide for ourselves and our loved ones is another fundamental component of self-identity. Financial identity creates expectations about how much we should be earning and our standard of living. Trauma at work can have significant impacts on our financial identity through the fear of job loss or the threat of income loss. Workplace abuse and trauma can shatter our sense of financial security and independence. Physical Identity: Our physical identity defines how we physically exist in the world; it is 307

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fundamental to our daily life. Having positive physical well-being gives us the ability to hold a job, play with our children, go for walks, go to the gym, and move freely without pain. If physical movement is a core part of your work, and you rely on physical abilities for income, your physical self will be even more strongly connected to your identity. An illness, injury, and aging can take a severe toll on our physical self. Workplace sexual and physical violence threatens our physical identity by taking away the control we have over our bodies. A loss of self-worth often accompanies the loss of physical identity.

The impact of trauma results in the loss of several self-identities, and this can be difficult to reconcile. Our view of the world is connected to our identities, especially when shaken by trauma or loss. Changes to self-identity profoundly impact the lens we use to interpret and filter the world around us. Before the trauma, we may have held the beliefs that the world is fair, had an optimistic perspective, been a happy person, or felt the world was predictable and safe. After trauma our beliefs about our world can leave us feeling negative, jaded, pessimistic, or unable to engage with people or activities in the ways we used to. When we experience loss, we’re often focused on the tangible things we’ve lost, such as our career, the job, the income, or our former colleagues. Mourning forces us to examine the intangible aspects of what we’ve lost—our relational, professional, financial, and physical identities. Some people may discover positive aspects of their changed self-identity and develop a renewed confidence. Others may uncover a more compassionate, kind, and caring part of themselves. Still others may unearth an assertive and courageous new identity that empowers them to move forward with courage, strength, and tenacity. This stage of mourning is 308

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complete when we discover our “new self.” Stage 5: Searching for Meaning A mourner’s understanding of the meaning of life is shaken by witnessing people dying, experiencing violence, being assaulted, being bullied, or by living through a destructive event. Our world no longer feels safe; we question the meaning of life and sometimes return to our spiritual beliefs. In this phase of mourning, we make sense of our world by assigning meaning to what’s happened to us. Searching for meaning is a process of identifying what we’ve lost and then finding healthy and supportive meaning, so we again feel grounded and centered. Successfully navigating this phase of mourning challenges you to find your answers to complex life questions. The search for meaning and purpose following trauma is one of the most powerful ways of moving forward and transforming negative experiences into positive ones. Stage 6: Receiving Ongoing Support Processing feelings of trauma or loss takes time and can take place over a span of weeks, months, or even years. PTSD recovery is cyclical and takes the survivor on a journey where they must revisit their trauma and grief many times. This makes ongoing support critical to recovery, especially when mourners re-experience grief. Seeking Out Individuals Who Honor Our Need to Mourn It is unrealistic to expect that after we find closure, our grief suddenly ends. Wolfelt (2016) comments that Western culture supports an “it’s over and done with, so put it behind you” 309

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approach to grief. Wolfelt (2016) identified three distinct approaches to grief: • • •

Group 1 is neutral: This group neither hurts you nor helps you. Group 2 tries to take your grief away: This group tries to cheer you up or tells you to carry on. Group 3 honors your need to mourn: This group helps you integrate your experience and loss into your life so you can move forward.

Recovery requires us to seek out individuals who honor our need to mourn. It is vital for us to honor that need by encouraging an internal dialogue of compassion, kindness, support, and understanding. We have a responsibility to create an environment, both internal and external, that respects the healing process and helps us find inner calm.

We can never return to who we used to be before the trauma or reclaim what we’ve lost. Mourning makes it possible for us to heal from the trauma and become a stronger, more creative, and resilient person. Letting Go The process of letting go happens when you’ve worked through the stages of grief and mourning and feel strong enough to move forward by putting the past behind you. The letting go process is a shift in perspective, a fresh way of looking at our present and past. The process of letting go is rarely straightforward because we’re holding onto an attachment that we must let go of before we can move forward, and that takes energy. At first you might go back and forth between periods of acceptance and times of inner conflict, but eventually you’ll settle into a place of inner calm, peace, acceptance, and gratitude. Stage 1: Compassionately support yourself through denial and bargaining. In this stage of letting go, we must be 310

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compassionate and accept that our conflicted state blocks us from letting go. Between periods of denial and disbelief, followed by times of inner struggle and bargaining, you might wonder, “Why did this have to happen to me?” and “Why am I so unlucky?” You may also be in denial about what you’re holding on to, and you may not be able to identify the specific attachment. Stage 2: Recognize what you’re holding on to. Letting go begins when we start the process of releasing what we’ve been holding on to. The clearer you are about what you’re struggling to let go of, the easier it will be to release it. Letting go requires you to break through the denial and bargaining you experienced earlier. Over time you will become more conscious of what you’re attached to and need to let go of. The recognition process requires the following steps: Thinking through what you’re holding on to Taking an objective point of view Exploring what could be blocking you from letting go of it Contemplating what you’re holding on to through inner exploration Stage 3: Knowing it’s okay to let it go. Making time to cultivate a deeper connection with yourself will naturally reduce the importance of what you’re holding on to. Deliberately choosing to release the thoughts or emotions you’re stuck on will let them go. If you find yourself ruminating, gently yet firmly remind yourself to free your mind’s grasp on those thoughts. Do this as many times as you need to until it becomes automatic. 311

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The Many Ways of Letting Go Letting go of changing relationships Letting go will give you a new perspective on your relationships. You may conclude that you need to accept the realities of certain people in your past and present. Understanding, accepting, and working through the impacts of those people is part of the process. Letting go of disappointment Letting go also means becoming more aware of how you’ve contributed to your relationships, both past and present. One of the most effective tools is practicing gratitude and appreciation so you can release the negativity that may be holding you back or making you feel stuck. Being invested in expecting a particular outcome from an individual often leads to disappointment. Expectations keep you stuck because you become afraid of specific anticipated outcomes.

Letting go of your limitations Your self-limiting beliefs can define who you are. If you think, “I could never do that!” or “I could never make that happen!” and truly believe it, you’ll never accomplish your goals. Opening your mind and believing in yourself is the key to letting go of your limitations. Many people will tell you that you can’t do something. It’s up to you to prove them wrong. Letting go of control over others You only have control over yourself and how you act. Letting go of the need to control others means accepting that you can’t change another person. It is important to remember that there is nothing you can do to get the outcomes you desire when dealing with others. When you’re abused, bullied, assaulted, or traumatized by someone, you can and should hold them accountable. When you do that, you accept that you cannot control them or receive the outcome you desire. Only then can you let go of blaming yourself for what happened. Letting go of what others think of you Freeing yourself from being controlled by what other people think starts by prioritizing how you feel about yourself. You can’t live by your values if you’re living for the approval of 312

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others. Letting go of your flaws It’s important to leave room for mistakes. Take your life experiences and learn and grow from them. If you’ve made a mistake or haven’t achieved what you wanted, you’re not stupid or a failure. You’re human.

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Workbook Exercises Workbook Exercise 4-1: A conversation with your “inner child” What is “inner child work”? We were all, at one time, children, and the child you once were didn’t just get replaced by a perfectly formed, responsible adult. All of us still occasionally act like children. For example, it can happen when you feel abandoned when you learn your partner is going away for a three-week business trip. Part of your unconscious mind is represented by the child you once were and shows up in the form of another personality during social interactions. This other personality is referred to by psychologists as your inner child. This exercise is a form of self-discovery to help you access the child you once were, along with the experiences and emotions you learned to suppress and hide. Although it can seem strange or uncomfortable at first, there are real benefits to this exercise:

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•

Accessing repressed memories that are holding you back

•

Being able to feel emotions after years of being numb or disconnected from them

•

Learning how to take better care of yourself

•

Feeling self-compassion and supporting a positive selfimage

•

Gaining personal power

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Words of Caution If you’re feeling too terrified to try this exercise, it might be a sign you’ve experienced extreme childhood trauma. If that’s how you feel, I recommend skipping this exercise and working with your support professional to explore those painful childhood memories. Working with a trained professional for support is vital in these circumstances. Goal The objective is to make an effort to contact, listen to, communicate with, and nurture your inner child so you can view your adult issues though a new lens. Acknowledging what happened doesn’t fix your concerns, but it can start your grieving process so you can move beyond the abuse. Instructions •

Find a quiet space where you can focus on what you’re thinking and feeling.

•

Set up two chairs facing each other and sit down in one of them.

•

Imagine your child self is sitting opposite you.

•

Give your younger self a name, such as “Little Steve” or “Little Cathy.”

•

Speak directly with your younger self and address them by name.

•

Reassure them that you’ll always keep them protected, safe, and loved (for example, “Hi, Little Cathy. I’m here to protect you and will always keep you safe. I’m your friend, and I love you.”) 315

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•

Ask your inner child to tell you what your adult self doesn’t know or has suppressed.

•

Move to the chair reserved for your inner child and sit quietly for a moment.

•

Speak loudly whatever comes to your mind.

•

Let your inner child express their emotions, fears, anxieties, concerns, and thoughts.

This exercise will help awaken your adult self to thoughts and emotions that have been suppressed or forgotten. For example: “My inner child told me about a violent incident that happened with my Dad when I was 16 years old. He spoke to my adult self in an angry tone and precisely described what happened one particularly painful night. Rediscovering the violence from my Dad helped me understand how I react to abusive people as an adult.” Journal What You’ve Learned Once you’ve completed the exercise, journal what you’ve learned from the exercise to remind yourself of the details.

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Journal What You’ve Learned

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Journal What You’ve Learned

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Workbook Exercise 4-2: What stage of grief am I in? Elisabeth Kübler-Ross, in her book On Death and Dying (1969), identified and described the universal grieving process for people in many cultures and across different walks of life. She identified five stages that are easy to understand and recognize. People who are grieving do not necessarily go through the stages in the same order or experience all of them: 1. Denial and isolation 7. Anger 8. Bargaining 9. Depression 10. Acceptance Grief can sometimes feel overwhelming and confusing. It is comforting to know where you are in the grieving process so you can celebrate what you’ve accomplished and prepare for what’s coming next. Keep in mind that everyone grieves differently. Some people wear their emotions on their sleeves; others will experience grief internally and not cry. Try not to judge yourself for the way you experience and express grief. Goal This exercise will help you identify which stage of grief you’re working through at the moment. Remember that grief is a personal process with no time limit and no single “right” way to do it.

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Instructions

Stage 1

•

Review all the stages of grief in the table below.

•

Identify the stage(s) that describe where you are today.

•

Jot down any thoughts or ideas that come to mind in the Notes column.

Stage of Grief

Characteristics

Denial and Isolation

The first reaction to loss is to deny the reality of your situation.

Describes where I am today

❑

• You may tell yourself, “This isn’t (or can’t be) happening.” • It is completely normal to rationalize your overwhelming emotions. • Denial is a common defense mechanism that buffers the immediate shock of the loss and numbs your emotions. • You might hide from the facts. • You might start to believe that life is meaningless and holds no value. This stage is usually temporary, carrying you through the first wave of pain.

Stage 2

Anger

As the numbing effects of denial and isolation begin to wear off, the reality and the pain associated with that reality re-emerge. You deflect intense emotions because you feel vulnerable and experience anger. • You may tell yourself, “I'm not ready.” • You direct your anger at inanimate objects, strangers, friends, or family. • If you’ve lost part of your identity, you might direct your anger internally, even though rationally you know you’re not to blame. • On an emotional level, you may resent the source of the pain. • You may feel guilty for being angry, and this may make you even more upset.

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Stage 3

Stage of Grief

Characteristics

Bargaining

Bargaining is a defense mechanism that protects us from our painful reality.

Describes where I am today

Notes

❑

• You may be asking yourself “if only” statements in an attempt to regain control and fight feelings of helplessness and vulnerability (for example, “If only I’d stood up for myself”). • You may make a deal with a higher power to try to postpone the inevitable and the accompanying pain. • You may be experiencing guilt. • You may believe you could have done something differently to change the painful outcome you’re experiencing.

Stage 4

Depression

Two types of depression are associated with this stage of grief. The first is a reaction to the practical implications of the loss:

❑

• Sadness and regret predominate this type of depression. • You worry that you’ve spent less time with others who depend on you. • Practical cooperation and a few kind words will help you overcome this type of depression. The second is more subtle and private: • It is your quiet internal preparation to say goodbye to what you’ve lost.

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Stage 5

Stage of Grief

Characteristics

Acceptance

In this last phase, you come to terms with the circumstances surrounding your loss. Acceptance doesn’t mean you’ll feel good or right about the loss: • You accept that you cannot go back to the old reality (before the loss). • You begin to see how the new reality you’re experiencing will impact your life and relationships. Acceptance means you embrace a new reality: • You will welcome the present, both good and bad, so you can begin to shape the future. • You will take ownership of yourself and your actions. • You begin to accept responsibility for your new reality. • You will find yourself focusing on accomplishing tasks and feeling proud of the results. • You will identify new priorities. • You may need to let go of some areas of your life that are no longer compatible with your new reality. Acceptance means reaching out to others: • You may start to reach out to trusted people and become more involved with your friends and family again. • You will need to form new relationships. Acceptance means growing contentment with your life: • You will feel more content as you journey toward a more “normal” life. • You will experience a sense of calm and acceptance.

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Describes where I am today

❑

Notes

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Workbook Exercise 4-3: Build your grieving self-care plan Goal Self-care is an essential way of being kind to ourselves while we grieve. It takes energy, understanding, and patience to go through the grieving process. This exercise walks you through the many ways of being kind to yourself so you can find comfort. Instructions •

Review all the grieving self-care options in the table below.

•

Identify the ones that interest you and you want to add to your grieving self-care plan.

•

Jot down any thoughts or ideas that come to mind in the Notes column.

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Self-Care

Details

Interests Me

1.

Take care of yourself physically

Grief can take its toll on your physical well-being. It’s essential to do your best to get adequate rest, eat regularly, and take part in some physical activity.

❑

2.

Forgive

Even in the best of relationships, there are usually memories that need healing. While you grieve your loss, areas of hurt or regret may enter your mind. Permit yourself to forgive yourself or others who have hurt you. It isn't easy, but it’s an essential step in the process of letting go.

❑

Consider adding a creative activity to your weekly activities as a way to work through the hurt and express forgiveness. A few examples are journaling, writing/playing music, composing poetry, taking photographs, or creating artwork. If your hurt is deep and painful, consider seeking professional help. Sometimes you cannot let go until you work through other issues first. 324

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Self-Care 3.

Explore your spirituality

Details

Interests Me

Times of solitude, inspirational reading, reflection, singing, playing a musical instrument, meditation, and worship help us find comfort and enlightenment throughout the grieving process.

❑

Notes

During your times of spiritual exploration, allow yourself to be open to your inner guidance. Listen to the whispers of your heart and soul.

4.

Make peace and have a conversation with the parts of yourself you’ve lost

During moments of solitude, perhaps late at night or early in the morning, reflect on the parts of yourself you may be grieving or have forgotten.

❑

Consider writing several letters to the parts of yourself you’re grieving or have lost. In the first letter or two, openly express whatever feelings you might be experiencing. Try not to censor yourself. If you feel angry, lonely, depressed, fearful, happy, or relieved, say so. Allow yourself to say what’s on your mind and express your thoughts in your letters. Then write yourself a letter of gratitude that expresses your appreciation for the person you’ve become.

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Self-Care 5.

Treasure and cherish fond memories

Details Treasure fond memories of your past that bring you comfort and make you happy. Create lasting positive memories you can go back to in the days ahead.

Interests Me

❑

Consider gathering mementos in a scrapbook, putting together a video collage of photos collected over the years, gathering friends together for a night of video games, or hosting a potluck dinner for family and friends. Allow yourself to enjoy all your beautiful memories. Treasure those memories and let them be lifelong companions that comfort you and make you happy. 6.

Share your pain and hope with others

Give your grief a voice, share your pain, and express your hope for the future. Consider connecting with at least one person you trust and respect in terms of sharing your emotions. Consider seeking professional counseling. Consider attending a support group, 12-step program, or psychotherapy group.

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Notes

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Self-Care 7.

Be patient and accepting of yourself

Details

Interests Me

Grief is the way you arrive at a place of acceptance and peace after loss. The only way to resolve your grief is to journey through it and get to the other side.

❑

Notes

Try to accept your feelings, whatever they may be. Although painful, they allow you to experience your emotions.

8.

Complete your “unfinished business”

Try to be aware of anything associated with your loss that feels unfinished.

❑

Consider completing whatever you feel is vital to allow you to reach a place of closure.

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Self-Care 9.

Be kind to yourself

Details Dealing with loss can be challenging. Give yourself special care, including taking the time to rest, eat healthy food, exercise, and socialize with friends and family.

Interests Me

❑

Be your own gentle and understanding friend. Do things with yourself you would do with a close friend who is suffering.

10.

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Let yourself cry

Crying promotes relaxation and releases your tension and sorrow.

❑

Notes

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Self-Care

Details

Interests Me

11.

Tune into what you’re feeling

Let yourself experience whatever you’re feeling; depression, anger, fear, guilt, regret, loneliness, relief, or peace. Pay attention to your body and your feelings as they arise.

❑

12.

Reach out to others

Though you’ll likely need time to yourself, it’s also vital that you share your thoughts and feelings with others.

❑

Notes

Find a few people you respect and trust and pour out your heart. Let your friends and family know what you need from them, such as a listening ear, a hug, or time together.

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Self-Care 13.

Postpone unnecessary changes

Details

Interests Me

Try to delay any significant decisions or unnecessary changes. Give yourself some time before deciding to move or making a career change.

❑

Focus your energy on grieving and healing. You will have a fresher perspective and more energy to move on after you’ve resolved your sadness.

14.

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Accept difficult memories

Grief brings up many difficult and painful memories. You may blame or punish yourself for not being able to protect yourself. But you’re not the only one to ever make mistakes or have regrets. Forgive yourself, learn from the painful times, and then let them go.

❑

Notes

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Self-Care

Details

Interests Me

16.

Surround yourself with things that are alive

Invite other living things into your life, such as a new plant, a pet you’ve always wanted, or a fresh bowl of your favorite fruit.

❑

17.

Be adventurous

After you’ve given yourself the space to grieve and heal, you can embark on a fresh new life adventure. Meet some new people or explore new places or ideas. Let yourself dream, then follow your heart and take a chance with something new.

❑

Notes

Adapted From: Kübler-Ross, E. & Kessler, D. (2005). On grief and grieving. New York, NY: Scribner. 331

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Select your top four self-care activities, commit to one or more activities, set a time frame, and add notes to help you get started.

e.g.

Self-Care Activity

What I commit to doing

Time frame

Notes

Be adventurous

Visit my local museum to learn more about sculpture.

Next week

Get the address and hours of the museum.

Research local sculpture classes so I can develop a new creative hobby. 1.

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Research continuing education art classes.

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Self-Care Activity

What I commit to doing

Time frame

Notes

2.

3.

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Self-Care Activity

What I commit to doing

Time frame

Notes

4.

Workbook Exercise 4-4: What stage of mourning am I in? Mourning has five stages: 1. Acknowledging your reality 2. Embracing your pain and loss 3. Shifting your perspective 4. Developing a new self-identity 5. Searching for meaning Mourning can sometimes feel overwhelming and confusing. It’s comforting to know where you are in the mourning process so you can celebrate what you’ve accomplished and prepare for what’s coming next. Keep in mind that everyone mourns 334

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differently; try not to judge yourself for the way you experience and express sadness and loss. Goal This exercise helps you identify the stage of mourning you’re working through at the moment. Remember that mourning is a personal process with no time limit and no “right” way to do it. Instructions •

Review all the stages of mourning in the table below.

•

Identify the stage or stages that describe where you are today.

•

Jot down any thoughts or ideas that come to mind in the Notes column.

Stage of Mourning Stage 1

Characteristics

The task to be completed:

• You confront the reality that your life has changed. • You acknowledge that you can never return to your past.

Considerations:

• You may push away thoughts of your traumatic experience because they are uncomfortable and painful to relive. • Support from a trained professional is an essential part of recovery at this stage.

Acknowledging Your Reality

Describes where I am today

Notes

❑

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Stage 2

Characteristics

Signs this stage is complete:

• You find yourself describing your trauma and loss as if it happened in the past.

The task to be completed:

• You acknowledge and interact with our pain. • You replay the events and experiences in your mind. • Each time you recall the experiences, you gain more acceptance. • You gradually accept the trauma, loss, and pain.

Considerations:

• You may need to distract yourself from the flashbacks and painful memories. • You may need to create a safe place inside yourself to recover. • Shift your internal dialogue to a friendly, compassionate, and loving “inner voice.”

Signs this stage is complete:

• You feel acquainted with your trauma, pain, and loss. • You feel compassionate toward yourself and what you’ve been through.

The task to be completed:

• You look to the future. • You open yourself to new experiences. • You embrace what you’ve been through. • You accept the past.

Considerations:

• Remembering and sharing the past makes hoping for the future possible.

Embracing Your Pain and Loss

Stage 3 Shifting Your Perspective

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Describes where I am today

❑

❑

Notes

Grieving, Mourning, Letting Go, and Moving Forward Stage of Mourning

Stage 4

Characteristics

Signs this stage is complete:

• You begin to consider what you want to do with your life.

The task to be completed:

• Your self-identities feel broken. • You feel like you’ve lost who you are. • You’re forced to rebuild your identity.

Considerations:

• The impact of trauma results in the loss of several self-identities, and this can be difficult to reconcile.

Signs this stage is complete:

• You discover a “new self” after going through the process of exploring and discovering who you are now.

The task to be completed:

• Your search for meaning and purpose. • You make sense of your world by assigning meaning to what’s happened. • You transform negative experiences into positive ones.

Considerations:

• Your understanding of the meaning of life is shaken. • Your world no longer feels safe. • Your search for meaning and purpose is one of the most powerful ways of moving forward.

Developing a New Self-Identity

Stage 5 Searching for Meaning

Describes where I am today

Notes

❑

❑

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Characteristics

Signs this stage is complete:

Describes where I am today

Notes

• You find answers to the complex life questions you’ve been grappling with.

Workbook Exercise 4-5: Developing a new self-identity Our view of the world is connected to our identities, and the impact of trauma results in the loss of several self-identities. The mourning process breaks them down and forces us to rebuild them. Goal Explore your self-identities and identify what’s changed following your traumatic experience. Instructions

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•

Identify any self-identity changes you’ve observed after your traumatic experience.

•

Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes

Relational Identity

I observe changes to my friendship network.

❑

I observe changes to my professional network.

❑

I observe changes to my social calendar.

❑

I observe changes to my feeling of community and connection with others.

❑

Relational identity is the component of self-identity that comes from our relationships with others.

Change observed

Describe the changes you’ve noticed.

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Types of SelfIdentity

Professional Identity Professional identity is the component of self-identity

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Self-Identity Changes

Change observed

I observe changes in my family relationships.

❑

I observe changes in my friendships.

❑

I observe other changes.

❑

I observe changes to my job title.

❑

Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes

Change observed

that comes from our work and career.

I observe changes to my duties at work.

❑

I observe changes to my skills and knowledge at work.

❑

I observe changes to my profession (career change).

❑

Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes I observe changes to my employment status

Change observed

❑

(unemployed, leave of absence).

Financial Identity Financial identity is the component of self-identity that comes from our ability to provide for ourselves and our loved ones financially.

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I observe other changes.

❑

I observe changes in my sense of financial security and independence.

❑

I observe changes to my income.

❑

Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes

Change observed

I observe changes to my financial stability.

❑

I observe changes to my ability to take care of myself financially.

❑

I observe changes to my ability to take care of people who depend on me financially.

❑

I fear job loss.

❑

Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes

Change observed

I perceive the threat of income loss.

❑

I observe other changes.

❑

Physical Identity

I observe changes to my physical abilities.

❑

Our physical identity is the component of self-identity that comes from how we physically exist in the world.

I observe changes to my health.

❑

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Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes

Change observed

I observe changes to my body.

❑

I observe changes to how I feel about my sexual desirability (this may be particularly relevant if you’ve been sexually assaulted).

❑

I experience physical pain.

❑

Describe the changes you’ve noticed.

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Types of SelfIdentity

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Self-Identity Changes

Change observed

I experience fatigue and loss of energy.

❑

I experience changes to my ability to move freely and without pain.

❑

I experience changes to my self-worth.

❑

Describe the changes you’ve noticed.

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Types of SelfIdentity

Self-Identity Changes

Change observed

I experience changes to my ability to take care of people who depend on me.

❑

I experience changes to my feeling of physical control over my body.

❑

I experience changes to my feeling of physical control over my environment and my life.

❑

I experience other changes.

❑

Describe the changes you’ve noticed.

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Workbook Exercise 4-6: Managing a forced employment transition Sometimes workers are forced into an employment transition such as being laid off, terminated, or forced to quit through a variety of underhanded tactics. I’ll walk you through practical ways to cope with this situation and build an action plan. When you get the news, your initial reaction will most likely be shock (and sometimes relief). This shock is the prelude to a grieving process that parallels getting over a divorce, death, or other traumatic loss. You’re faced with emotional, financial, and professional concerns as you work through the next steps: •

Putting your employment transition in perspective

•

Seeking and receiving support and assistance

•

Organizing your job search.

You will go through several distinct emotional stages—shock and denial, anger, bargaining, depression, acceptance, and hope—of varying durations and intensities. Purpose This exercise suggests strategies for coping with the emotional, practical, and professional effects of a forced employment transition. An increased awareness of the psychological impacts will help you recover from the trauma and start anew. Mourning Your Loss There is no set schedule for mourning a forced employment transition. While some people complete the process in a matter of days or weeks, others need more time. If you’re struggling to 348

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work through this transition, find a support professional (life coach, social worker, or psychologist) to help get you moving again. No matter how traumatic it might feel, losing your job need not be catastrophic. You can turn what feels like a devastating personal tragedy into a personal and professional triumph. The vast majority of professionals not only survive termination but find another position that is at least as satisfying if not more. Gaining Perspective During the first stages of mourning, you may struggle to put what’s happened to you in perspective. It may feel like the end of the world, and you will likely experience these feelings: •

Shock and Denial: “This can't be happening to me.” Denial functions as a buffer, initially protecting you from strong emotions, such as anger, and allowing you to continue functioning. If you anticipated your termination, you might feel relief at no longer having to work under stressful conditions.

•

Anger: “How can they do this to me?” or “How did I let this happen?” You may be angry at your boss and the company for rejecting you and perhaps mistreating you. You may be mad at yourself, feeling frustrated, or even embarrassed you didn’t see the writing on the wall.

Managing the Shock As challenging as it may be, your priority is to manage your emotions so you can deal effectively with the immediate financial impact and professional concerns. Weigh your words 349

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and actions against their potential effect on your future during the critical time between getting the news and permanently leaving your workplace. Although the duration of this period varies, it is typically brief. It may be difficult to leave behind projects and the organization in which you’ve invested so much, especially if you received little notice. Wrapping up your professional responsibilities may be a topic you wish to explore with your supervisor. Keeping your head is vital in obtaining the best possible termination package and securing favorable references, which will be an essential element in securing future employment. Useful Tips Here are some things you can do as soon as you get the news: • Check your company handbook for a formal termination policy. • Request a little time to collect your thoughts before discussing your termination package, severance pay, and other benefits. If possible, make an appointment for another day. • Ask for outplacement assistance to help you get reemployed. • Go home. No one expects you to finish the day. • There’s no need to explain to coworkers what has happened immediately. • Prepare a written agenda for your final meeting. Include all your concerns and information needs. Coping with the News It’s vital to your professional concerns to manage your emotions 350

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at the workplace, so find a safe place to vent your feelings and cope with your emotions after you hear the news.

Useful Tips Don’t hesitate to seek professional help. Forced job loss is a significant life trauma; you may need specialized assistance in coping with your distress and putting the change in perspective. It helps to talk things out with a trusted listener with the following characteristics: • • • • • • •

Not involved in your professional life Discreet Let’s you do the talking Makes reflective statements Encourages you to open up Refrains from making judgmental remarks Doesn’t rush you into making decisions

Alcohol and other drugs do not help and should be avoided, if possible. Forced employment transitions are stressful, but there are steps you can take to • Improve your separation package; • Minimize the disruption in your life; and • Find a new position more quickly.

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Define Your Reason for Leaving Useful Tips Ask your HR representative why you’re being let go: As you try to put your termination in perspective, it helps to have a clear understanding of why it happened. The need for corporate restructuring may be influenced by conflicts of personality, strategy, or philosophy. It may help in your next job to know the role of any such disputes in your termination. Establish an acceptable explanation of your termination with your employer to use in job interviews and reference statements: Get it in writing, if possible. Be sure that the key contacts at your former workplace have the explanation and stick to it. Use a logical reason for leaving the statement: When prospective employers check your references, they will be looking for agreement between your story and that given by others. Use the same "reason for leaving the statement" with everyone, starting with your family. Terms of Forced Employment Transition The final meeting to discuss this package is your most significant opportunity to ask questions and to receive the best terms. Useful Tips Consider the following subjects in formulating your written agenda for your final meeting to discuss terms. • Advance notice: How much? What about pay in lieu of notice? 352

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• Severance pay: How much? How is it paid? Some experts advise periodic payments instead of lump-sum payments, if possible. Periodic payments relieve you of the responsibility of handling a lump sum during the initial phase of the crisis, and it simulates a paycheck. • Vacation pay: How much accumulated leave do you have? Are you entitled to payment for unused vacation time? What about unused sick leave, overtime, or compensatory time? • Pension, profit-sharing plans: What benefits are due to you? Clarify them and check with an employment lawyer if you have any concerns or questions. • Health insurance coverage: How long will it last? What will it cost? Review your policy regarding any grace period. • Life and disability insurance: How long will coverage continue? Check your policies. • Other employee benefits: Will these continue for a specified term? Refer to the employee handbook to avoid overlooking anything. • Transfer or rehire privileges: Do any apply to your case? Ask for a detailed explanation. Take notes during the termination interview and request a written record of your termination package from your employer. Tie up any loose ends such as company credit cards, company car, outstanding travel reimbursements, and personal possessions. significant opportunity to ask questions and to receive the best terms. 353

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Critical Consideration Before signing any agreement, consult a lawyer specializing in employment law to go over the details. Never sign the paperwork on the day you receive it. Unemployment Insurance In most termination cases, you have the right to claim unemployment insurance benefits. This insurance has been previously paid for by you and your employer. It is not charity. Consider it an employee benefit or a dividend on an investment now come due. •

Report to your unemployment insurance office.

•

Expect an interview with an unemployment insurance officer, either in person, or on the phone.

•

File the necessary forms.

Useful Tips Upon notification of eligibility, you may have to report regularly to the unemployment office or are required to file reports. Make sure you complete these required steps on time to ensure you receive your unimplemented insurance funds without any interruptions or delays. Remember, you have the right to tap every existing financial resource so that you can focus your full attention on your job search. 354

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Managing Home Life You should be able to expect support and concern from your family. One of the unexpected benefits of this challenging experience may be rediscovering loved ones and an affirmation of your intrinsic self-worth. Family and friends love you for who you are, not for what you do as a job. Useful Tips How do you break the news to family members that you’ve been let go? Don’t delay. Be direct and try to remain calm. • Explain first to your spouse, and then to your children, what’s happened, using the same “reason for leaving” language you agreed to with your supervisor. • Reassure them that the family will make it through this crisis. • Be honest about any anticipated changes in lifestyle. The post-termination period can be highly stressful for everyone, especially as financial pressures mount. Remember that all family members are affected by the employment transition. They may go through their own grieving process at their own pace and intensity. It is vital to keep the lines of communication open. Family members need to be prepared to answer questions. Talk through problems as they arise. When included in problem-solving, children can learn valuable life lessons that better prepare them to cope with adversity as adults.

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Survival Tactics Confront the financial imperatives of your particular situation head-on as soon as you can. You need to recognize that the job search process could be lengthy, and you need to do the most to maximize your financial resources and reserves.

Useful Tips • Review your budget and trim wherever possible: Consider your monthly expenses—dining out and entertaining, cable and Internet, clothing, home furnishings and renovations, charitable donations, RRSP contributions, and automatic savings deductions—and see where you can make some changes. • Don’t take a vacation right away: Besides the financial expenditure, there may be emotional repercussions depending on where you are in the grieving process. • Contact all your creditors, especially mortgagors and utility companies. Explain your situation and inquire about temporarily reducing your payments. • Many mortgages have a skip-a-payment feature. Check with your mortgage company or bank for details. • Debt consolidation: Depending on your family’s overall financial situation, consider seeking a debt-consolidation loan at a lower interest rate than any of your consumer debt. • Review all your resources: If you must tap into your savings, don’t feel guilty. You have saved before, and

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you’ll save again. Don’t make any rash financial or business decisions. Seek professional advice as necessary. Coping with Grieving, Bargaining, and Depression Think about all you’ve achieved up to this point: •

You’ve kept your head at your former workplace.

•

You’ve found someone with whom you feel comfortable talking things out and venting your feelings.

•

You’ve broken the news to family and close friends.

•

You’ve taken care of business and know where you stand financially.

The full impact of losing your job may hit you hard. This next stage of grieving, bargaining, and depression is the most difficult for many. Focus now on coping with your feelings and reach out for help in doing so. Family and friends can do much to restore your sense of self-esteem while diminishing the pain. •

Bargaining: “If I could only get my job back, I would...” You contemplate anything and everything you could do to get your job back or might have done to keep it. You may be feeling ashamed and regretful. At this stage, any bargaining you might initiate is undermined by your damaged self-esteem.

•

Grief reaction: For some, forced employment transitions trigger unusually strong reactions because of some unresolved past loss such as a parent’s death. If depression continues beyond a week or two, or if it interferes with your daily functioning, please seek 357

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professional support. •

Depression: “I’m just not any good. No wonder life is terrible.” You may have difficulty making decisions and may also experience appetite and sleep disturbances. Fatigue and a sense of having lost control contribute to your overall anxiety. You may experience a sense of loss most acutely at this time. Depression, the most severe stage, can lead to inactivity, which undermines any notion of a job search.

Depression is typically the most challenging stage since it’s not a productive time. Don’t expect to mobilize your job campaign while in the throes of depression. Help yourself by scheduling activities that give you a sense of accomplishment, no matter how small. Concentrate on one task at a time. See it through to completion. Useful Tips Combat social isolation: Recognize and guard against a tendency to avoid others. • Join a support group of people coping with forced employment transitions. • Plan social activities with friends. • Keep communication open with family members. • Maintain your professional associations and contacts. Exercise: Start the day with some physical activity. A regular exercise program provides some discipline and structure to your day. Treat your exercise time as you would an important meeting. The physical activity will help alleviate mild depression 358

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as well. Your mental outlook and emotional well-being will improve along with your fitness level. The idea is to feel good physically—don’t set specific self-improvement goals that leave you frustrated and worn out. Use relaxation techniques: Check out your local library, bookstore, or health food store for literature or tapes that teach simple relaxation techniques. Practice daily to help recharge your battery and alleviate stress. Read self-help literature: Check out some books and articles dealing with job loss, job hunting, life transitions, employment transitions, and career change. Other subject areas worth investigating are psychology, spirituality, and counseling. This reading can provide helpful insights and serve as preliminary research for your job search strategy. Completing the Final Stage of Mourning In the final stage of mourning, your focus shifts from looking back to looking forward. Ask yourself this question to determine whether you’re in the grieving process: “What’s my problem?” If you answer, “I lost my job,” you’re still mourning the past. If you answer, “I need a job,” you’re coming to terms with your situation and are ready to focus on the future You will experience these feelings: •

Acceptance: “It’s not the end of the world, just the end of one job.” You’re at peace with what happened and experience a sense of quiet expectation that something good may come out of it. You have mourned the loss of your job and the people and places left behind and are 359

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ready to look ahead and start exploring the possibilities. •

Hope: “I’ve got a lot of options open to me.” By accepting what’s happened, you’re suddenly open to all that may be. The final stage of mourning finds you standing taller, smiling more often, speaking with newfound confidence. Now you can begin to organize for your job search. Remember, though, that this time between jobs will hold its share of disappointment and rejection. You will continue to cope with painful feelings and may even find yourself repeating a phase of mourning you thought was completed. But it can also be a time of growth and self-renewal.

Set Up a Workspace and Schedule You’re newly self-employed: Finding a job is a full-time job. Get off to a good start by organizing your workspace. •

Create a workspace, whether it’s a permanent or portable setup.

•

Record a professional message on your voicemail.

•

Talk to your family about answering your cellphone or home phone professionally and ask them to take messages.

•

Plan for your document preparation and printing needs: resumes, cover letters, and follow-up correspondence.

•

Calculate the expenses of running a job search campaign.

Once you have your workspace organized, set up a schedule for using it. Block off specific times for particular tasks in your 360

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personal calendar. For example: •

Making and receiving professional phone calls

•

Writing job search materials: resumes, reference statements, and letters

•

Conducting career research

•

Keeping up with professional literature

•

Continuing physical exercise

Refine Your Job Search Skills Post-job-loss success doesn’t happen overnight. There are many variables in estimating how long it will take you to find a new job. It could take many months, so invest time early on in refining your job search skills. This period of unemployment provides you with an opportunity to assess your career and plan its future development. Don’t narrow your options. Now may be the time to start using some of your other talents. Consider an in-depth evaluation of these career possibilities: •

Furthering your education in a new or related field

•

Pursuing continuing education in your current field

•

Taking a new track in your present career

•

Starting a new career

•

Relocating

•

Seeking a position in a smaller company

Explore your options if you were to act on any of the above suggestions. You need a clear concept of the job you’re seeking 361

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to target your search correctly. Take these steps to help define the right job for you: •

Inventory your accomplishments, skills, and interests.

•

Don’t restrict your list to on-the-job activities. Include part-time and volunteer work that incorporates additional skills such as leadership, fundraising, or team orientation.

•

Review your inventory for likes and dislikes.

•

Imagine your ideal job.

•

If outplacement counseling is made available to you, use that time for consultation. Or, you may wish to seek career counseling independently.

Network Your Way to a New Job Personal contacts account for the overwhelming majority of new positions found by previously terminated employees, but don’t put your friends and professional acquaintances in an awkward position by asking if they have a job for you. Instead, get them working for you as advisers. Ask them to review your resume and keep them informed of your background, abilities, and career goals. Ask them who in their professional network they could introduce you to. Then the ball’s in your court after a quick LinkedIn intro. What you don’t want is to make them feel like they’re the ones looking for job opportunities for you. If you have someone close you can help you rework your resume, that’s great, but I wouldn’t suggest that you keep them all updated as you add new elements. 362

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Remember, many termination packages offer employment assistance that includes resume prep. When networking, cast a wide net. Begin with a select group of relatives, close friends, and professional acquaintances and then expand this network by asking them to provide you with the names of their professional contacts you might contact to further your job search. •

Maintain contact with former work colleagues and professional associates.

•

Maintain membership in your professional organizations, especially at the local level.

•

Enroll in a professional development course to develop new marketable skills or to hone your present abilities.

•

Try to arrange informational meetings with personnel in organizations you favor as prospective employers.

•

Summarize your career accomplishments and aspirations in a 30-second elevator pitch.

•

Volunteer your professional services if you have the time.

•

Many school systems are looking for volunteers to help augment their science programs.

•

Join a local job finding club.

Make Full Use of the Internet The Internet is a great source of information when you’re looking for a job. You can locate information on immediate opportunities in a confidential environment or gain access to other job seekers and share experiences through email or social 363

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media, as well as get the message out that you’re available. Recruiters and companies advertise available positions online, and most employers prefer to receive resumes through their online submission systems. Find Interim Employment Finances may require you to find some interim employment while looking for the right job. You may be able to find work within your field, either as a consultant or on a temporary or contract basis. You could also consider other skills that you could put into practice to secure interim employment. For example, do you have a hobby with vocational value? Could you market it? Evaluate Trade-Offs During your job search, you’ll face periods when you have to consider different options and make trade-offs:

364

•

There are costs associated with any career change. Keep in mind that they’re not exclusively financial.

•

Keep in mind your head, heart, and home life as well when evaluating career decisions and potential job situations.

•

Consider the trade-offs and assess them in terms of both short- and long-range goals.

•

Evaluate any direct expenses of continuing education or relocation. Either may ultimately yield greater professional fulfillment or better pay and benefits.

Grieving, Mourning, Letting Go, and Moving Forward

Begin Your New Adventure There is life after a forced employment transition. The period between jobs can be a time of growth, renewal, and a time for a new beginning. Positive change can be anxiety producing and stressful yet also extremely rewarding. The message from those who’ve survived termination is a positive one. You will emerge with increased self-knowledge, fresh career perspectives, and redefined priorities. Keep in mind these tips: •

Find ways to keep the flame of self-renewal burning.

•

Be kind to yourself, both in body and spirit.

•

Acknowledge your frustrations and disappointments.

•

Try to have patience.

•

Remind yourself that things worth being are better than things worth having.

•

Consider any day that contains something of beauty, love, discovery, or growth a day well spent.

Moving Forward Moving forward from workplace PTSD is possible with patience, understanding, reflection, and with the support of a trained professional. Here are a few ideas to keep in mind as you work on moving beyond your PTSD. Accept the things you cannot change: Stop wishing things could be how they used to be. Live in the present moment because that’s where life happens. Accepting that you cannot change the past will set you free, so you can focus your energy on making decisions that will create the future you want. 365

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The healing power of a sense of humor: Don’t take yourself too seriously; relax and enjoy life’s journey. When you laugh, your brain releases dopamine, which gives you a rush of pleasure that reinforces positive change. Become fearless: Do what scares you and live your life’s adventure. Fear holds you back from experiencing new things and closes your mind to exciting future possibilities. Fear and doubt make you question yourself and dissuade you from trying new things. The more you try moving out of your comfort zone, the more fear will subside, and the more you’ll grow. Find your voice: Find your voice and share with others what you’re thinking and feeling. If you communicate what does and doesn’t work for you, you won’t be bottling up your emotions. Expressing yourself is an integral part of feeling good about yourself and your relationships. Continue learning and evolving: Resentment and unwillingness to forgive will keep you locked in the past and prevent you from moving forward. When you forgive, you aren’t doing it for the other person; you’re doing it for yourself. When you reach a place of forgiveness, you can let go. Advocate for positive change: The way forward is to have more people acknowledge the reality of workplace abuse. Management will be forced to change work systems when employees and the public demand positive change.

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Grieving, Mourning, Letting Go, and Moving Forward

Synopsis •

PTSD survivors experience pain and loss from their trauma; this inevitably leads to grief.

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When survivors begin the recovery process, they wish things would have ended differently, better, or less painfully.

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Trauma changes you; your “before self” seems to vanish, leaving your “after self” grieving whom we used to be.

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Grief carries us through the stages of denial, anger, bargaining, depression, and acceptance.

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Individuals with complex PTSD often suppress their emotional reaction to trauma and begin recovery after they acknowledge their emotions in a safe environment.

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Mourning makes it possible to heal through the process of adapting to loss over several months.

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PTSD recovery is cyclical and takes the survivor on a journey where they must revisit their trauma and grief many times.

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The process of letting go begins when grief and mourning are complete and you’re strong enough to put the past behind you.

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Moving forward is possible with acceptance, humor, fearlessness, learning to express yourself, continuing to evolve, and advocacy.

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Grieving, Mourning, Letting Go, and Moving Forward

FINAL THOUGHTS Introduction As you already know, PTSD recovery doesn’t go in a straight line. What worked for others may not work for you, and what works for you today might not work all the time. The goal of recovery is to make progress in the right direction over a sustained period. The process of learning requires your brain to interpret, organize, integrate, uptake, and implement the longlasting changes you’re working toward. If you move forward too quickly without giving yourself time to make sense of all that you’ve learned, you risk becoming overwhelmed. Expect to go through periods of growth followed by slower periods when you feel you’re not making progress. During the slower times, your mind is working quietly in the background consolidating everything you’ve learned. Since PTSD recovery is an intense emotional experience of ever-changing and sometimes painful emotions, learning to manage the internal and external stimuli that trigger traumatic memories and emotions takes time and patience. You need to take time to regulate those emotions. During times of positive movement forward, you’ll find balance and strength. Conversely, when your perspective becomes more negative, your progress might feel slow and laborious, and you may even experience emotional overload. Permit yourself to journey through these ups and downs compassionately. Trust that you will find a healthy balance. 369

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Even though you’ll sometimes feel like you’re up against a wall, the truth is that you’re always farther along than you think. When you remember emotions and experience from your past, you’ll be transported back to your state of mind on that day and make sense of what you went through. Trust in the recovery process because you’re making progress every time you cycle back to your past experiences. Over time, you’ll find your way through it and get to the other side. But take note of what’s making you feel like you’re going backward. These are usually negative thoughts, actions, or emotional reminiscences from an earlier time. Ask yourself: What would it take to replace your thoughts, actions, or emotions with more positive ones? Then choose an action and take it. The process of selecting an action that empowers you will give you the confidence and strength to make that choice again in the future.

Building and Maintaining Your Network One of the best ways to protect your life from being disrupted or destroyed by an abusive person is to build and maintain a healthy network of supportive advocates. The presence of social support is one of the best protective factors against developing PTSD as well as a predictor of better treatment outcomes (Lazarus & Folkman, 1984). People who are more sociable and have an active social network show higher self-worth and confidence, which both provide an inoculating effect against the development of PTSD (Yuan et al., 2010). The quality of the available social support was much more critical in the protective effects of social support than the size of the social network 370

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(Kessler, Price, & Wortman, 1985). PTSD symptoms have been linked to the loss of social support; PTSD survivors tend to isolate themselves, and traumatized people can be challenging to be around, especially if their symptoms are severe. When PTSD survivors are encouraged to seek out support and are supported in the development of more positive attitudes toward their illness, they are more likely to take full advantage of the support networks available to them (Clappa & Beck, 2009). Another critical factor to discuss when considering social support is whether the PTSD survivor perceives the support as negative or positive. Positive support is perceived as a reaction of empathy, understanding, consistency, and reassurance. PTSD survivors who receive positive support see a benefit in the form of improved recovery. Conversely, PTSD recovery is impeded if survivors have social support in place but receive negative or hurtful feedback after the traumatic event (Zoellner, Foa, & Bartholomew, 2005).

Healthy Coping Another way to empower yourself is by practicing healthy coping habits. Actively coping will help you feel a sense of control over your health and your circumstances. Hopefully, you have already incorporated some of these strategies into your everyday life. If not, think about turning some of these skills into habits so that you can be prepared for the stressful times ahead. 371

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Pay attention to your sleeping habits: Poor sleep harms your emotional and physical health. Achieving high-quality sleep can be challenging for PTSD survivors, but the good news is that sleep problems will diminish as you work through your abuse and trauma. As you focus on your recovery, try some of the following ways of combatting sleeping problems: Why Do People with PTSD Have Sleeping Problems? PTSD survivors may be “on alert”: Many PTSD survivors feel they need to be on guard to protect themselves from danger, so they have difficulty getting high-quality sleep, either through difficulty falling asleep or waking up easily in the night. PTSD survivors may have bad dreams or nightmares: Nightmares are frequent for people with PTSD and make for a restless sleep; worrying about whether they’ll have a nightmare can also make it difficult to fall asleep. PTSD survivors may have physical problems: Physical problems such as chronic pain, stomach problems, and muscle cramps can make getting enough high-quality sleep challenging. PTSD survivors may worry or have negative thoughts: Worrying about general problems or having negative thoughts can make it difficult to fall asleep. Then worrying that they won’t be able to fall asleep can create a vicious cycle that keeps them awake. PTSD survivors may have substance abuse issues: Using drugs or alcohol to help cope with PTSD symptoms can disrupt and impede restful sleep. Alcohol affects sleep quality and makes it less refreshing. The same is often the case for drugs, especially stimulants. Consider these other possible ways of combatting sleeping problems:

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When you receive professional support and work through your PTSD symptoms, your sleep quality will improve.

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Exercise during the day; avoid working out within three hours of bedtime, since exercise temporarily stimulates the heart, muscles, and brain.

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Avoid heavy meals, nicotine, caffeine, and alcohol in the evening.

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Try to avoid napping.

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Make your sleeping space as comfortable as you can.

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Set the temperature at a comfortable level.

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Practice relaxation techniques, such as meditation or progressive muscle relaxation.

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If you’re having trouble falling asleep, go into another room and engage in a quiet activity until you feel tired.

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Avoid using backlit electronic devices such as laptops, tablets, and cell phones three hours before

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bed; research has found that the light emitted by these products interferes with the body’s sleepregulating system.

Connect and build your support network: Talk to your doctor or support professional about your PTSD symptoms. Medication can help reduce feelings of depression or anxiety. A professional can help you develop coping skills and provide support if you feel disconnected from your loved ones. Healthcare providers can also help you overcome any unhealthy coping habits such as smoking, substance abuse, or alcohol use. Consider reaching out to trusted family and friends. Talking about your feelings can keep you from feeling isolated. Another option is to join a support group and share your story with other survivors, so you know you’re not alone. Get involved in activities you enjoy: You may find yourself avoiding social situations or activities you used to enjoy. Staying active can be a positive distraction, will improve your mood, and helps reduces stress. Setting weekly goals can encourage you to keep moving. Personalize your goals and make them reflect your interests by completing a hobby project, taking your dog for a walk, or meeting a friend for coffee. After you achieve your goals, treat yourself with rewards that reinforce the positive nature of your activities. PTSD is a natural response to an abnormal event. By actively participating in your recovery using healthy coping strategies, you take control of your life and arm yourself with powerful and effective recovery tools. 373

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Workbook Exercise 5-1: Healthy coping exercise Empower yourself by practicing healthy coping habits. Using active coping methods will help you feel a sense of control over your health and your circumstances. Goal Identify your healthy coping skills and turn them into habits so you can successfully navigate the stressful times ahead. Instructions •

Select some of the items in the table below to turn into healthy coping habits.

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Add your own ideas to personalize your list.

Categories of Healthy Coping

Healthy Coping Activity

Encourage healthy sleeping habits

Receive professional support so I can work through PTSD symptoms; this support will lead to improved sleep quality.

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Exercise during the day.

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Avoid working out within three hours of bedtime. Exercise temporarily stimulates my heart, muscles, and brain, making it challenging to fall asleep.

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Avoid heavy meals, nicotine, caffeine, and alcohol in the evening.

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Try to make it through the day without napping.

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Make changes to my sleeping space to make it more comfortable.

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Reduce light from alarm clocks and other electronic devices.

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Select and turn into a habit

Final Thoughts

Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Set the temperature at a comfortable level, preferably around 19 °C or 65 °F, to improve the quality of my sleep.

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Practice relaxation techniques, such as meditation or progressive muscle relaxation, before sleep.

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If you’re still having trouble falling asleep, go into another room and engage in a quiet activity until you feel tired.

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Avoid using backlit electronic devices such as laptops, tablets, and cell phones at least two hours before bedtime. Research has found that the light emitted by these products interferes with the body’s sleepregulating system.

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Add your ideas below:

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

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Engage with support professionals

Set weekly activity goals

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Talk to my doctor or a support professional about my PTSD symptoms.

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Work with my support professional to explore medication that can help reduce feelings of depression or anxiety.

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Talk to my support professional about developing effective coping skills.

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Ask if my support professional can provide support if I feel disconnected from my loved ones.

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Ask if my support professional can help me overcome any unhealthy coping habits, such as smoking, substance abuse, or alcohol use.

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Join a support group and share my story with other survivors, so I know I’m not alone.

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Personalize my activity goals, so they reflect my interests.

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Set weekly goals to encourage myself to keep moving.

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Plan and complete a hobby project. For example, regularly taking my dog for a walk, meeting a friend for coffee on Tuesday evenings, or redesigning a room.

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After you meet your activity goals, treat yourself with rewards that reinforce the positive nature of your activities.

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Final Thoughts

Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit Add your ideas below:

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Participate in diversion activities

Write, draw, paint, or take photos.

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Play an instrument, sing, or dance.

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Take a shower or a bath.

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Garden.

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Take a walk or go for a drive.

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Watch television or a movie.

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Watch calming or fun videos on YouTube.

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Play a game.

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Go shopping.

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Clean or organize your environment.

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Read.

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Engage in social and interpersonal coping activities

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Talk to someone you trust.

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Set boundaries and practice saying “no” when you need to set clear boundaries.

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Write a note to someone you care about.

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Final Thoughts

Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Be assertive.

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Do something fun that appeals to your sense of humor.

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Spend time with friends and family.

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Volunteer or help someone in need.

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Care for or play with a pet.

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Role-play challenging situations with others.

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Encourage others.

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Join a local support group.

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Sign up for a course that develops your interests or hobbies.

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Add your ideas below:

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

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Develop cognitive coping skills

Make a gratitude list.

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Brainstorm solutions.

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Work on lowering your expectations of your situation.

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Keep an inspirational quote with you.

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Be flexible.

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Write a list of goals.

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Take a class.

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Act the opposite way your negative feelings are making you feel.

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Write a list of pros and cons for decisions.

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Reward or pamper yourself when successful.

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Write a list of strengths.

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Accept a challenge with a positive attitude.

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Add your ideas below:

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

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Practice tension reduction activities

Exercise or play sports.

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Engage in catharsis (yelling in the bathroom, punching a punching bag).

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Laugh and cry.

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Baking and cooking.

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Daydream and envision yourself the best way you can.

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Take care of and play with pets.

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Scream and swear in a safe, private setting to reduce stress.

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Garden, water plants, landscape, or mow a lawn.

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Go to a sauna or a hot tub to relax.

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Meditate, practice mindfulness, or go to a yoga class.

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Add your ideas below:

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Participate in physical self-care

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Get enough sleep.

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Eat healthy foods.

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Final Thoughts

Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Get into a good routine.

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Limit caffeine use.

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Practice deep breathing.

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Tune into your

Pray or tune into your spirituality.

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

spirituality.

Meditate.

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Enjoy nature.

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Get involved in a worthy cause that helps others.

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Paint, dance, sing, or create.

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Add your ideas below:

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Set limits

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Drop some involvement.

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Prioritize important tasks.

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Use assertive communication.

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Final Thoughts

Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Schedule time for yourself.

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Add your ideas below:

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Stay away from harmful coping activities

Avoid, reduce, or eliminate recreational drug use.

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Avoid, reduce, or eliminate alcohol consumption.

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Avoid, reduce, or eliminate engaging in selfmutilation.

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Avoid, reduce, or eliminate ignoring or bottling up feelings.

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

Avoid, reduce, or eliminate taking sedatives.

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Avoid, reduce, or eliminate taking stimulants.

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Reduce working too much.

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Stop avoiding your problems.

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Try to stop being in denial by being honest with yourself.

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Add your ideas below:

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Strengthen your mental state and build resilience to 386

Participate in activities and be around people that help you build your confidence.

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Final Thoughts

Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

life’s stressors

Accept compliments when they’re given.

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Make time for your loved ones.

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Give support to others when needed and accept support from others when needed.

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Create and stick to a realistic budget.

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Volunteer in your community.

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Find ways to manage your stress regularly.

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Add your ideas below:

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Categories of Healthy Coping

Healthy Coping Activity

Select and turn into a habit

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Monitoring for Signs of Potential Relapse A person with a substance use problem is considered to have relapsed if they go back to regularly drinking or using drugs after a period of abstinence. The term relapse can also be applied to PTSD recovery. PTSD symptoms can come and go over many years. A PTSD relapse is the return of enough symptoms to again meet the criteria of a PTSD diagnosis. Though you might not have a full relapse, you may find yourself slipping into old patterns of thought or behavior. Being aware of the warning signs of a potential relapse will allow you to intervene early with healthy coping strategies. Managing the symptoms of PTSD takes effort and requires the regular use of healthy coping skills. Sometimes stressful experiences or changes in mood may make it difficult to maintain these skills. For instance, PTSD survivors may notice themselves using avoidance behaviors such as isolating from loved ones or unhealthy coping strategies, substance abuse, deliberate self-harm, or binge eating. These behaviors are warning signs that PTSD symptoms could be returning or becoming worse—in other words, a PTSD relapse. An essential PTSD recovery skill is learning how to catch a relapse early and course correct. 388

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Relapse prevention is a set of skills designed to reduce the likelihood that PTSD symptoms will worsen, or unhealthy behavior will return. Relapse prevention skills include •

Identifying early warning signs that symptoms may be worsening;

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Recognizing high-risk situations that increase the risk of relapse; and

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Understanding how seemingly mundane decisions may lead to relapse (for example, skipping a meal can greatly change a person’s mood).

PTSD Relapse Warning Signs See if any of these relapse warning signs are consistent with your experience. Remember that everyone's PTSD symptoms and signs are unique. I encourage you to compile a personalized list of warning signs that are specific to you and your situation. Changes in Your Thinking •

“I don’t care about going to therapy anymore.”

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“Nothing is working out for me. I’m never going to get better.”

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“No one cares about me or what I do. What’s the point of going on?”

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“I’m feeling a little down. This must mean that I’m going to fall into a deep depression again.”

Changes in Your Mood •

“Everyone is getting on my nerves lately.”

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“I just don’t feel happy, even when I’m around people I love.”

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“I’m beginning to feel jumpy and on edge.”

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“My mood keeps changing. In minutes, I can go from feeling happy to down or terrified.”

Changes in Your Behavior •

“I don't have the energy to take care of myself. I haven’t showered for days.”

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“I don’t want to be around people anymore. I’ve been isolating myself.”

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“I’ve been drinking more but just to take the edge off my feelings a little.”

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“I’ve noticed that I’m less talkative than I used to be.”

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It’s unreasonable to expect PTSD symptoms never to be triggered because triggers are out of our control. Symptoms don’t usually appear out of the blue; often they are preceded by some warning signs. Those signs could be the experience of specific emotions, shifts in thinking, or changes in behavior. Relapse prevention skills help you identify the early warning signs of the return or worsening of your PTSD symptoms, allowing you to take quick preventive action. As well, awareness of your warning signs may make the return of PTSD symptoms feel more predictable and less unexpected. Recognizing the warning signs allows you to cope with these changes before they become unmanageable. Once you’ve identified your warning signs, build an action plan for each of them. I encourage you to share your warning signs with a trusted loved one so they can be on the lookout for them and help you cope if one surfaces. Coping with Suicidal Thoughts and Behaviors If you don’t have a support professional and are experiencing suicidal thoughts, it's vital to get a psychiatric or psychological evaluation and begin work with a support professional as soon as possible. Suicidal thoughts are a sign that you need professional help with your PTSD symptoms. Talk with your support professional •

Some support professionals have ways for their patients to contact them if they’re in crisis or having suicidal thoughts; check to see if your professional support has a system like this.

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They can help you assess the seriousness of your situation and assist you with ways of coping with those thoughts.

Talk to someone supportive

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Social support can be an excellent way of coping when you’re in crisis. Call a family member or friend. Let them know you need someone to talk to and would like their support or change your environment by asking them if you can spend some time with them.

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Call a suicide prevention hotline to talk to someone.

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Go to an emergency room •

This can feel scary, but if your coping strategies aren’t lessening suicidal thoughts, it's essential for you to stay safe and alive.

Go somewhere safe •

Identify several public places you can go where you would be less likely to hurt yourself, such as the mall, a coffee shop or restaurant, a community center, or a gym. Once you’ve immersed yourself in that environment, pay attention and be mindful of the sights and sounds around you so you can put distance between you and your suicidal thoughts.

Stay away from weapons •

A suicide attempt will be more likely to occur if you have the means readily available to you, such as guns, knives, other weapons, or potentially harmful medications in your home. Remove these dangers from your environment or go to a place where you won’t have access to them.

Manage your mood •

Many coping strategies, such as expressive writing or self-soothing, can help manage your mood. By improving your mood, you may also improve your thoughts, reducing your risk of suicide.

Challenge suicidal thoughts •

When people feel down and depressed, it’s common to have thoughts that are consistent with those moods; once your moods change, your thoughts will change along with them.

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If things feel hopeless, it may be a consequence of your mood and not necessarily how things are; use self-monitoring to identify and challenge hopeless thoughts:

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Is it not possible that your mood might change?

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Is there no hope for the future?

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Have you felt like this before, and if so, did things eventually get better?

Be mindful of your thoughts •

Take a step back from your thoughts and watch them. Taking a mindful approach to thoughts of suicide or hopelessness can reduce them, limiting the power they have over your actions and mood.

Source: Tull, 2018

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Workbook Exercise 5-2: PTSD relapse warning signs Goal Identify your PTSD relapse warning signs and build action plans that will help you minimize the chance of a potential relapse. Instructions •

See if any of these are consistent with your experience but remember that everyone's PTSD symptoms and signs are unique.

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I encourage you to compile a personalized list of warning signs that are specific to you and your situation.

Indicator

My PTSD Relapse Warning Signs

Changes in My Thinking

“I don’t care about going to therapy anymore.” “Nothing is working out for me. I’m never going to get better.” “No one cares about me or what I do. What’s the point of going on?” “I’m feeling a little down. This must mean that I’m going to fall into a deep depression again.”

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My Action Plan

Final Thoughts

Indicator

My PTSD Relapse Warning Signs

Changes in My Mood

“Everyone is getting on my nerves lately.”

My Action Plan

“I just don’t feel happy, even when I’m around people I love.” "I’m beginning to feel jumpy and on edge." "My mood keeps changing rapidly. In minutes, I can go from feeling happy to down or terrified." 393

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Indicator

My PTSD Relapse Warning Signs

Changes in My Behavior

"I don't have the energy to take care of myself in the morning. I haven't showered for days." “I don’t want to be around people anymore. I’ve been isolating myself.”

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My Action Plan

Final Thoughts

Indicator

My PTSD Relapse Warning Signs

My Action Plan

“I’ve been drinking more, but just to take the edge off of my feelings a little.” “I’ve noticed that I’m less talkative than I used to be.”

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Changes in Your Mood: •

“Everyone is getting on my nerves lately.”

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“I just don’t feel happy, even when I’m around people I love.”

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"I’m beginning to feel jumpy and on edge."

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"My mood keeps changing rapidly. In minutes, I can go from feeling happy to down or terrified."

Changes in Your Behavior: •

"I don't have the energy to take care of myself in the morning. I haven't showered for days."

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“I don’t want to be around people anymore. I’ve been isolating myself.”

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“I’ve been drinking more, but just to take the edge off of my feelings a little.”

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“I’ve noticed that I’m less talkative than I used to be.”

Once you’ve identified your warning signs, come up with a plan of action. You can turn to a mental health professional to help with this.

Workbook Exercise 5-3: My relapse prevention plan When learning how to cope with PTSD symptoms, it is vital to have a relapse prevention plan. A relapse prevention plan is valuable to have throughout recovery and beyond. Relapse prevention skills help you identify the early warning signs of the return or worsening of your PTSD symptoms. Building an action plan for each early warning sign allows you to take quick 396

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preventive action. Goal •

Recognizing high-risk situations that put you at risk of relapse.

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Understanding how seemingly mundane situations and triggers may put you on the path to relapse.

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Identify protective factors and coping strategies to prevent a relapse.

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Establish a relapse prevention action plan.

Details It is common for PTSD survivors to experience external reminders of the traumatic experience that lead to an acute stress response. These external reminders are called triggers. Identifying and being aware of your triggers empowers you with the power to avoid them. Relapse triggers can be broken into a few groups that are easily overlooked. Hungry, angry, lonely, tired: Avoiding becoming too hungry, angry, lonely, or tired. Emotions: Perceived negative emotions often lead people to use drugs or alcohol in the first place and can easily lead a person back to their drug of choice. Stress: Losing a job or loved one, increased responsibility at home or work, and health problems can all create increased stress. The key here is being proactive about stress prevention 397

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and being mindful and honest about what causes stress for you. Overconfidence: Having self-confidence is necessary but becoming overconfident to the point of complacency creates a risk for relapse. You might think you’re strong in your recovery and put yourself in increasingly risky situations. Mental or physical illness: Depression, anxiety, and other underlying mental illnesses can trigger a relapse. Physical illness and pain can also put you at risk for relapsing, as your body is stressed. Social isolation: Reluctance to reach out to others or form a support system can lead to social isolation and loneliness. Social anxiety can also be a struggle during recovery. Social situations or places: Another one of the most common relapse triggers is putting yourself in situations where PTSD symptoms are triggered. Be aware of the people, places, and things that act as triggers. Instructions

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Complete the relapse prevention plan.

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Keep a printed copy with you or have a copy available on your smartphone, tablet, or other electronic device.

Final Thoughts

Identify your high-risk situations.

Identify your triggers.

1. Hungry, angry, lonely, tired

2. Emotions

3. Stress

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Identify your high-risk situations. 4. Overconfidence

5. Mental or physical illness

6. Social isolation

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Identify your triggers.

Final Thoughts

Identify your high-risk situations.

Identify your triggers.

7. Social situations or places

Identify your healthy coping strategies that act as protective factors. Protective factors allow you to put distance between yourself and your unhealthy behaviors. Remove yourself from a dangerous situation as soon as you can, and this will take away the triggers for that behavior.

Identify your coping strategies for stress. Healthy coping strategies include seeking social support, distracting yourself, using selfsoothing exercises, or practicing mindfulness. Actively coping will help you feel a sense of control over your health and your circumstances.

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Identify your high-risk situations.

Identify your triggers.

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Identify your high-risk situations.

Identify your triggers.

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Identify your high-risk situations.

Identify your triggers.

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Establish your action plan. What will you do if you’re concerned about a potential relapse? 1.

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Identify your emergency contacts. 1.

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Managing Setbacks with Compassion PTSD survivors are at higher risk of engaging in many unhealthy behaviors in an attempt to cope with their emotional pain. These behaviors are not easy to stop because they serve an essential purpose. In the short term, they help survivors escape the frequent, intense, and unpleasant thoughts and emotions that occur with PTSD. A person recovering from PTSD may find that under periods of high stress, they start engaging in one or more of these unhealthy coping behaviors: •

Impulsivity to commit self-destructive behaviors

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Alcohol and drug abuse

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Eating disorder behavior

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Deliberate self-harm

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Promiscuity and sex addiction

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Suicidal behavior

Replacing these unhealthy coping behaviors with positive strategies helps PTSD survivors handle time of high stress more effectively. Some of these healthy alternatives are: •

Distraction

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Replacing impulsive behaviors with healthy ones that serve the same functions

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Identifying the long-term negative consequences of behaviors

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Changing the consequences of a behavior

It is essential to do whatever you can to unlearn these unhealthy 407

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behaviors since the habits become stronger the more you engage in them. Try these ways of coping with setbacks so you can quickly get back on your road to recovery. Practice self-compassion: Changing unhealthy behaviors is not easy, especially when you’re struggling with symptoms of PTSD. Treat yourself with understanding and compassion if you have a setback. Use the misstep as an opportunity to further strengthen your coping repertoire. Doing this will help you get back on track and also move you down the road to recovery. View it as a setback, not a failure: Be gentle on yourself by viewing a setback as temporary; it doesn’t indicate failure and isn’t a sign that there’s no hope for recovery. During recovery, we may place expectations on ourselves, such as “I will never drink alcohol again” and while it may be a great plan, lofty goals may not always be realistic, especially if you’re in the early stages of PTSD recovery. When you set black-and-white rules for yourself, you’re more likely to beat yourself up about a slip, and this will likely motivate the behavior you’re trying to stop. As a result, you may lose control over the behavior and experience a recovery setback. Being kind, compassionate, and forgiving toward yourself is critical to help you through these temporary missteps so you can get back on track without beating yourself up. Avoid your triggers: If you’re in a situation that promotes your unhealthy behavior, remove yourself from that situation as soon as you can, which will also remove your triggers. Identifying and being aware of your triggers empowers you to avoid them. Develop healthy coping strategies: This plan may be 408

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challenging during a crisis, and initially, you may feel the strategies aren’t working, but it’s important to keep trying to incorporate them into your life. The more you do so, the more distance you’ll put between yourself and your unhealthy behaviors. Healthy coping strategies include seeking social support, distracting yourself, using self-soothing exercises, or practicing mindfulness. Learn from your setbacks: A setback can provide you with incredibly valuable information that can serve you well in the future. Managing setbacks prepares you with proven skills that enable you to cope with and avoid future high-risk situations. Ask yourself, what were the factors that led to that behavior? How did I get into the high-risk situation? Analyzing your unhealthy behavior will help you identify powerful enablers. On the surface, these seemingly irrelevant choices may appear insignificant, and you may ignore, deny, or explain them away. Once you look more closely at these “chains of events,” you may learn that they take you down the road toward a setback.

Finding a Healthy Workplace If you lost your job or had to leave a job because you were traumatized, finding a healthy workplace to return to is an empowering recovery decision. Choose your next job based on the health of the organization, and you will never regret your decision. Liz Ryan (2016; 2018), former Fortune 500 Human Resources SVP and workplace thought leader, considers a healthy work environment to be led through trust rather than by fear. The “fear versus trust” level in an organization is not only 409

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the most essential thing you need to know about a prospective workplace but is a predictor of the organization’s success or failure. The following characteristics of a trust-based workplace make it highly unlikely it will support or facilitate workplace abuse and trauma. Employees are trusted and valued: In trust-based organizations, employees have flexible schedules and can work from home. No matter how loudly a CEO or marketing department proclaims their organization has a “great culture,” if they really do, they trust their employees enough to let them get the work done where and when they choose. Organizations with strict attendance policies, especially for salaried employees, are stuck in fear. The exception is a job where there is a health and safety aspect to arrival and departure times. When you ask about the organization’s employee handbook, they openly show you a copy. The handbook of a healthy workplace will be concise and written in clear, conversational language. Healthy organizations don’t do performance reviews or 360-degree feedback because they trust the people they hire. They make goals individually and collectively and mostly achieve them. You are treated with respect throughout the interview and hiring process: Regardless of whether you get the job or not, you are treated respectfully. In a healthy workplace, interviewers and other people you meet talk to you like a new friend. They’re honest about the challenging parts of the job and the irritating things that can happen in a typical workday. They don’t get offended when you ask questions such as, “What’s the worst part of the job?” or “What’s your manager 410

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like?” Employee interactions are happy and engaging: In a healthy workplace, the culture and atmosphere in the work environment are positive and supportive. Employees will talk happily with each other, joking and walking around. In a fearful workplace, in comparison, you’ll see defensive body language, employees hunched over their desks, and people watching the clock. Everybody understands what the organization does and why: In a well-run workplace, everybody you meet understands what the organization does and why. They know the mission and their part in achieving it. There’s no secrecy about any of the organization’s activities. In other words, the environment is open and honest. Jobs are built around projects and initiatives rather than a list of tasks: In healthy organizations, projects are aligned with the organization’s mission. Make sure you can identify the mission for any job you apply for. Without knowing the mission, you can’t make an informed decision about whether you’re the right person for the job, and neither will the organization. Job descriptions focus on challenges rather than job requirements: Written job descriptions and job advertisements in healthy organizations focus on the challenges the employee will tackle in the role, rather than a long list of “essential requirements.” Fear-based organizations impose the “right” way to perform the job rather than focusing on how employees can give them the results they’re looking for. 411

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Failure is embraced: Trust-based workplaces fail fast and fail often because it’s understood that from failure comes learning and success. Fear-based organizations see failure as a reason to reprimand an individual or terminate employment. The inherent message sent to employees in unhealthy workplaces is that if you fail, you’ll be punished. This subliminal message instills a culture of fear that trust-based organizations avoid at all costs. Team members in trust-based workplace cultures rally around each other and collaborate to find solutions to inevitable challenges and failures that are part of the evolution of any organization. Metrics will be primarily qualitative rather than quantitative: If you’re measured every day, hour, or half-hour on strictly quantitative measurements, your brilliance will never have an opportunity to show itself. Fearful managers are driven to control their subordinates with metrics because they’re easy to measure and document, especially when they need someone to blame. Leaders in healthy workplaces apply metrics sparingly and support all employees in bringing their individual contributions and creativity to work every day. There are few bureaucratic processes: Everybody in trustbased organizations, including leaders, wants the same thing, which reduces the need for bureaucratic procedures. Healthy workplaces encourage and support their employees to grow and thrive. They have a mission to follow rather than a bureaucracy to maintain. Hiring and promotions are based on competence, not politics: In a healthy organization, employees are hired or promoted into their roles because they are thoughtful, mature 412

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professionals. Fear-based workplaces promote based on politics and power dynamics. Workers can say what they want without fear of retribution: In a healthy organization, there is debate. Managers don’t get upset because an employee challenges them; they know they need to be challenged because the best ideas come from the most unlikely places. Nobody’s opinion is worthless, and nobody is told to shut up because the manager has already made the decision. These signs of a trust-based workplace are indicators that you’ll be treated with respect and dignity. Pay attention during the interview process, and if you see any warning signs of a fearbased culture, carefully consider if the opportunity is right for you. Being a PTSD survivor means you’re vulnerable to workplace trauma and abuse. Recovery means you must protect yourself against revictimization and self-advocate for a happier and healthier future.

Workbook Exercise 5-4: Healthy workplace checklist Goal Determine if an organization you’re interested in joining is a trust-based workplace where you’ll be treated with respect and dignity. If you see the warning signs of a fear-based culture, carefully consider if the opportunity is right for you. Instructions •

Pay attention during the interview process and use the checklist below to determine if the organization shows 413

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indicators of a trust-based healthy workplace. •

Tricky interview questions and observations will help you identify the indicators of a trust-based workplace.

•

The more indicators you identify and observe, the higher the likelihood that the workplace and culture are healthy, respectful, and dignified for their employees.

Indicator

Signs of a Trust-Based Workplace

Employees are trusted and valued.

Employees work on a flexible schedule and can work from home.

❑

There are no strict attendance policies.

❑

When you ask about the organization’s employee handbook, they openly show you a copy. The handbook is concise and written in clear, conversational language.

❑

The organization does not conduct performance reviews or 360-degree feedback because they trust their employees.

❑

Goals are set both individually and collectively.

❑

The organization has a track record of achieving the goals they set collectively.

❑

Regardless of whether you get the job or not, you’re treated respectfully.

❑

Interviewers and other people you meet with talk to you like a new friend.

❑

Interviewers and other people you meet are honest about the challenging parts of the job and the irritating things that can happen in a typical workday.

❑

Interviewers and other people you meet don’t get offended when you ask direct questions such as “What’s the worst part of the job?” or “What is your manager like?”

❑

Your time is respected and valued.

❑

You’re treated with respect throughout the interview and hiring process.

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Applies

Final Thoughts

Indicator

Signs of a Trust-Based Workplace

Applies

You’re directly contacted about the outcome of any interview steps honestly and respectfully.

❑

The culture and atmosphere in the work environment are positive and supportive.

❑

Employees talk and joke happily with each other while walking around.

❑

Employees don’t have defensive body language, such as sitting hunched over a desk, and don’t watch the clock.

❑

Everybody you meet understands what the organization does and why.

❑

Everybody you meet understands the mission and their contribution to achieving it.

❑

There’s no secrecy about the organization’s activities.

❑

The work environment is open and honest.

❑

Jobs are built around projects and initiatives rather than a list of tasks.

Jobs are built around projects and initiatives rather than lists of tasks.

❑

Projects are aligned closely with their mission.

❑

Job descriptions focus on challenges rather than job requirements.

The job description is not a laundry list of tasks and clearly describes the mission and goal of the role.

❑

Written job descriptions focus on the challenges the employee will tackle in the role, rather than a long list of “essential requirements.”

❑

The job description does not impose the “right” way to perform the role.

❑

The job description describes what employees can bring to the job that will lead to the results they’re looking for.

❑

The workplace’s culture supports failure because from it comes learning and success.

❑

Team members rally around each other and collaborate to find solutions to inevitable challenges.

❑

Employee interactions are happy and engaging.

Everybody understands what the organization does and why.

Failure is embraced.

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Indicator

Signs of a Trust-Based Workplace

Applies

Failure and lessons learned from missteps are part of the history and evolution of the organization.

❑

The principal metrics for the job will be qualitative, not quantitative.

❑

You won’t be measured every day, hour, or half-hour on strictly quantitative measurements.

❑

Leadership applies metrics sparingly.

❑

Leadership supports all employees in bringing their contributions and creativity to work every day.

❑

Success is described as a collaborative effort among teams.

❑

Success is defined based on team success, not exclusively individual success.

❑

Everybody in the organization, including leadership, wants the same thing.

❑

Bureaucratic processes are consciously kept to a minimum.

❑

Workers are encouraged and supported to grow and thrive.

❑

They have a mission to follow rather than a bureaucracy to maintain.

❑

Hiring and promotions are based on competence, not politics.

Employees are hired or promoted in their roles because they are thoughtful, mature professionals.

❑

Politics and power dynamics do not play a role in the hiring or promotion of employees.

❑

Workers can say what they want without fear of retribution.

Employees can speak up without fear of retribution.

❑

Vigorous and open debate is encouraged and supported.

❑

Managers don’t get upset because an employee challenges them.

❑

Managers appreciate that they need to be challenged because the best ideas come from the most unlikely places.

❑

Success metrics will be primarily qualitative rather than quantitative.

There are few bureaucratic processes.

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Indicator

Signs of a Trust-Based Workplace

Applies

Nobody’s opinion is worthless, and nobody is told to shut up because leadership has already made the decision.

❑

Synopsis •

Recovery is a process built on hope, choice, selfdetermination, and empowerment.

•

Recovery is possible for all people who live with PTSD.

•

PTSD survivors are resilient and know their own experiences of recovery.

•

PTSD recovery is more than reducing symptoms; it is the process of achieving your life goals and ambitions.

•

Taking responsibility for yourself and your actions is an essential goal of PTSD recovery.

•

Your recovery goals and journey are owned and created by you.

•

Recovery is brought to life by learning tools that you apply directly to your recovery.

•

Seeking support from others is essential for a successful recovery.

•

Recovery is a process that involves many stages and will include inevitable setbacks and uncertainty.

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418

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Webber, J. M., Mascari, J. B., Dubi, M., & Gentry, J. E. (2005). Moving forward: Issues in trauma response and treatment. American Counseling Association Knowledge Center. Retrieved from www.counseling.org Wingood, G. M., & DiClemente, R. J. (1998). Rape among African American women: Sexual, psychological, and social correlates predisposing survivors to risk of STD/HIV. Journal of Women’s Health, 7(1), 77–84. Wolfelt, A. D. (2016). The journey through grief: The six needs of mourning. Retrieved from: centerforloss.com Worden, J. W. (2008). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York, NY: Springer. World Economic Forum (2016). The future of jobs: Employment, skills and workforce strategy for the fourth industrial revolution. Geneva, Switzerland: World Economic Forum. World Health Organization (2004). Neuroscience of psychoactive substance use and dependence. Geneva, Switzerland: World Health Organization. Retrieved from www.who.int Wyatt, A., Caponecchia, C., Yun Zhi, A., & Sun, D. (2012). “Psychopaths” at work? Implications of lay persons’ use of labels and behavioural criteria for psychopathy. Journal of Business Ethics, 107(4). Yuan, C., Wang, Z., Inslicht, S. S., McCaslin, S. E., Metzler, T. J., Henn-Haase, C., Apfel, A. A., Tong, H., Neylan, T. C., Fang, Y., Marmard, C. R. (2010). Protective factors for posttraumatic stress disorder symptoms in a prospective study of police officers. Psychiatry Research, 188(1), 45–50.

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Index

INDEX A Acupuncture, 290 Acute Stress Response, 107, 111, 113 Amygdala, 165, 166 Anxiety, 18, 30, 47, 95, 107, 108, 110, 165, 169, 180, 187, 189, 277, 278, 281, 282, 290, 300 Anxiety Management, 282 Attachment, 310 Avoidance, 110, 290

B Blame the Victim, 43, 46 Bone Pain, 18 Brain Stem, 165 Brainwashing, 45 Burnout, 94

E Emerging Treatments, 283 Employee Morale, 19, 94 Employee Turnover, 96 Exposure Therapy, 279 Eye Movement Desensitization and Reprocessing, 279

F C

Cardiovascular, 19, 93, 170 Career, 11, 180, 183, 307, 308 Career Counsellor, 183 Coercion, 40, 48 Coercive Control, 43 Cognitive Behavioral Therapy, 278, 279 Cognitive Processing Therapy, 280 Cognitive Restructuring, 280 Cognitive Therapy, 167, 168 Complementary Treatments, 288 Complex-PTSD, 107, 115, 116 Corporate Hierarchy, 54 Couples Counsellor, 180 Crisis Situation, 192 Cyberbullying, 20, 21

D Defensive Reaction, 50 Denial, 7, 51, 310, 311

Depression, 18, 30, 94, 108, 116, 143, 180, 187, 189, 289, 290 Destabilization, 45, 51 Detachment, 116 Diagnostic and Statistical Manual, 187 Disasters, 2, 94 Discrimination, 18, 19, 27, 28, 31, 89, 165 Disinformation, 44 Divide and Rule, 45

False Beliefs, 44 Family Counsellor, 181 Fatigue, 18 Fight-or-Flight Response, 111, 112, 113, 165, 166 Finding Support, 190 Flashbacks, 3, 107, 109, 110, 113, 114, 116, 165, 299

G Gaslighting, 51, 52 Gastrointestinal Issues, 18 Gender Inequality, 29 Gossip, 45, 52 Grieving, 5, 299, 300, 301, 304 Grieving Process, 301, 303 Group Counsellor, 181 Guilt Tripping, 48

H Harassment, 18, 19, 21, 22, 23, 24, 25, 26, 27, 31, 93 Health Impacts of PTSD, 169, 170

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Recovering from Workplace PTSD Workbook Health Insurance, 192, 193 Healthy Coping, 371, 373, 408 Healthy Workplace, 409 Hidden Agenda, 50 Hippocampus, 165 Hormones, 111, 112 Hostile Work Environment, 27 Humiliation, 18, 299 Hypervigilance, 110 Hypnotherapy, 290

I Illness, 2, 28, 149, 186, 308 Inequality, 28, 29, 30 Initial Appointment, 194 Isolation, 45

J Job Stress, 97 Journalists, 95

L Letting Go, 310, 312, 313 LGBT, 22, 30 Licensed Professional, 193 Life Coach, 184, 287 Lifestyle Changes, 291 Love Bombing, 49 Lying, 44, 51

M Major Life Change, 181 MDMA, 285 MDMA-Assisted Psychotherapy, 285 Medial Prefrontal Cortex, 164 Medications, 277 Meditation, 290 Military, 154, 173, 285, 286 Mixed Messages, 47 Mourning, 5, 304, 305, 306, 309, 310 Moving Forward, 365 Muscle Aches, 18

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N Networking, 370, 373 Neuropsychologist, 188 Nightmares, 3, 109, 110, 372 Normalizing, 7 Numbing, 110

P Personal Boundaries, 49 Physical Abuse, 18, 31, 84 Physical Health, 18, 25, 169, 170, 423 Playing Hard to Get, 46 Poverty, 29, 30 Power, 24, 26, 29, 31, 40, 41, 44, 45, 46, 54, 116 Power Abuser, 26, 40, 41, 43, 44, 45, 46, 48, 54 Prefrontal Lobe, 164 Pregnancy, 28 Present Centered Therapy, 282 Professional Support, 7, 179 Projection, 46 Prolonged Exposure Therapy, 281 Propaganda, 44 Psychiatrist, 189 Psychological Abuse, 18, 84, 107, 262 Psychological Well-Being, 25 Psychologist, 186, 187, 188 Psychotherapist, 181 PTSD Symptoms, 116, 117, 171, 371 PTSD Treatment, 277

R Recovery Journey, 8 Recovery Plan, xiii, 6 Recovery Process, 5, 8, 11, 179, 299 Relapse, 388 Relapse Prevention, 389, 390 Repetitive Transcranial Magnetic Stimulation, 289

S S.M.A.R.T. Recovery Goals, 217 Scapegoating, 53 Self-Advocate, 5, 179 Self-Compassion, 408 Self-Entitlement, 42 Self-Esteem, 43, 180, 181

Index

Self-Identity, 6, 299, 307, 308, 338, 339, 340, 342, 344 Self-Medicate, 3 Self-Regulate, 52 Self-Worth, 42, 52, 308 Sense of Control, 54 Setbacks, 408, 409 Setting You Up to Fail, 45 Sexual Assault, 25 Sexual Harassment, 25, 26 Shame, 26, 41, 42, 48, 50, 116, 161, 278, 280 Short-Term Memory, 164 Sleeping Habits, 372 Social Ridicule, 45 Social Support, 170, 173, 262 Social Worker, 185, 186 Stages of Letting Go, 310, 311 Stages of Mourning, 304, 305, 306, 307, 309 Stereotypes, 21, 27 Stress Inoculation Training, 282 Substance Abuse, 170, 180, 181, 186 Suicide, 390 Suicide Prevention, 390, 391 Sympathetic Nervous System, 111

T

Testing Limits, 49 Toxic Leadership, 96 Toxic Work Environment, 53, 93, 96, 97 Traumatic Bonding, 43 Triggers, 107, 112, 113, 114, 408 Trust-Based Organization, 410, 413

U Unethical Behavior, 94, 95, 97

V Verbal Abuse, 18, 26, 84, 93, 97 Virtual Reality Exposure Therapy, 283 Vizualization, 291

W Weak Boundaries, 49, 54 Wellness Recovery Action Plan, 238 Withholding Validation, 48 Work Performance, 27, 44 Workplace Bullying, 18, 19, 20, 23, 24, 30, 31 Workplace Violence, 24, 93

Testing Boundaries, 54

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