Posttraumatic Stress Disorder (PTSD), as defined in the DSM-V, is characterized by 5 symptoms. The last four must last longer than a month and cause significant distress:

  1. Exposure to trauma: death or threat of death or injury.
  2. Intrusive symptoms: memories, flashbacks, psychological distress, physical distress.
  3. Avoidance: trying not to think about the trauma, avoiding places that remind you of it.
  4. Negative alterations in thought and mood: amnesia, negative beliefs, distorted cognitions, lack of interest, detachment, estrangement from others, inability to experience positive emotions.
  5. Arousal: Irritability, angry outbursts, reckless behavior, hypervigilance, exaggerated startle, difficulty concentrating, insomnia.

At root, PTSD is a survival mechanism, a battlefield mentality, intended to keep us safe. It’s the body’s way of saying, “Never again will I be abused, attacked or in danger.” It becomes a problem when the alarm system goes off in the absence of real danger. It becomes a problem when individuals attempt to suppress “dangerous” thoughts and emotions. Alcohol, hypervigilance, and checking will not make one safer, but they do temporarily silence the alarm. And they all amount to experiential avoidance. An earlier article on this site, Core Beliefs and Assumptions in PTSD, presented the case of Mike:

Mike, a 49 year old production packer, was involved in an accident and suffered third degree burns on the back of his right hand. He is right handed. He remembers watching the machine coming down on his hand. He remembers in vivid detail the smell of burning flesh. He sees himself as out of control as helpless, as defective. He holds some key assumptions:

  • If people look at my hand, I’m out of control. 
  • Spacing out, flashbacks, nightmares mean I can’t control my own mind.
  • If I can’t control my mind, I’m weak, out of control, helpless, and unable to function.
  • If I’m anxious, I’m losing control, I can’t function.
  • If I can’t control my emotions and thoughts, I’m helpless.
  • If I reveal any vulnerability, people will lose faith in me and view me as weak.  
  • If I avoid going out, I’m in control, I can function.
  • But if I avoid, I’m helpless; It proves how defective I am.

He sees danger everywhere. But most threateningly, he sees it inside. To manage such fear, he stays home, avoids people, and conceals his hand. He is wary around stoves and heaters. He tries to control his thoughts by avoiding all reminders of the injury. And all these strategies make him feel more out of control. Avoidance and hyper-vigilance are both cause and an attempted cure for his problems. His efforts to avoid distress perpetuate the distress. An article here by Aaron Brinen describes the power of exposure in correcting this strategy. Mike knows that the stove had nothing to do with his injury. But even looking at it unsettles him. He hasn’t cooked since the accident. Such avoidance significantly interferes with his life. Prior to setting up a hierarchy, he describes his reservations:

  • I could re-injure my hand.
  • It could really set me back.
  • It may be difficult doing this. I need to practice ignoring my mind.
  • The feelings will catch me off guard.
  • It takes too much effort to do this. I’m not ready.

These are real concerns that reflect 1) the risk of injury, 2) the lack of resources in preventing or dealing with the risk, and 3) the fear of distressing feelings. These beliefs are worthy of testing step by step through the use of a hierarchy. Next, he describes the benefits of avoidance:

  • It protects me from real danger.
  • It’s a habit. It comes naturally.
  • It combats the feeling.
  • I get a minute of peace.
  • I’m completely in control of my thoughts.

He acknowledges that avoidance works to prevent distress. And that in itself is reinforcing. So far, it would seem that such avoidance is a great coping strategy: don’t look at anything that distresses you. But it comes with significant costs. He generates a few:

  • It doesn’t really protect me.
  • It’s irrational. The stove had nothing to do with my injury.
  • I eat out. I order take out. It’s expensive and unhealthy.
  • It’s an overreaction. The situation doesn’t call for it.
  • It becomes depressing. It becomes hopeless.

He can go further. He can list the disadvantages of these disadvantages. He can elaborate on just how much of an inconvenience this creates, and how it leads him to see the worst in himself, his world, and his future. He can examine how this perpetuates the fear, and how it constricts his life. He acknowledges that he sees himself as more vulnerable, as weak. He recognizes how he is even more distressed by reminders and memories of the event. Taking all this into account, he compares the benefits and costs of such avoidance. It’s 80 to 20, against avoidance, and he is all the more willing to engage in exposure. He is all the more willing to test out the beliefs that made exposure scary, and avoidance attractive. Finally, he is ready to list and elaborate on the benefits of exposure:

  • I can start cooking again. I can feel comfortable in my own home.
  • I can improve the quality of my life. I can be less prone to anxiety.
  • I can feel more in control. I can get closure — I can end the saga.
  • I can get out of the rut. I can have more peace.
  • I can be a normal person. I can be free.

He can go even further here as well. He can list and elaborate on the advantages of these advantages. He builds up a vision of freedom as something attainable, something that can sustain him through the anticipated setbacks. Some clients are willing to take a chance at having their expectations disconfirmed, as described by Michelle Craske and colleagues. Others may need a degree of hope in order to get to the starting gates of exposure. Mike is just such a client. He greatly expands on this list of benefits, providing the necessary courage to take those first steps. The benefits of exposure outweigh the costs 80 to 20, and he is ready to test out his fears. He is ready to set up the hierarchy.

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