In the last section, we discussed the effects of triggers on PTSD clients and also various types of triggers: anniversary triggers, current stresses, and bodily triggers.
Now that we’ve discussed the various types of triggers, we will move on to coping strategies for the client’s reaction to these triggers.
In this section, we will present three techniques to help a PTSD client cope with their triggers: trigger coping questionnaire, writing, and abdominal breathing exercise. We will discuss PTSD resulting from combat and sexual abuse.
Cho, a 29 year old escaped refugee from North Korea, related her traumatic experiences while imprisoned in a communist detention center for singing a South Korean song. Cho stated, "They beat me, bad. Every day. After breakfast of rice, they would beat me, because they liked to see me throw up. I would go hungry until they fed me again the next day. The guards raped me and told me I was a traitor. They told me my family was dead and my husband was dead. I did not know if they were lying. Now when I smell rice, I want to throw up."
As you can see, one of Cho’s strongest triggers was rice. Her other triggers included the smell of blossoms and warmth because she was imprisoned during the warm blossoming season; the feeling of being dirty because she was not allowed to bathe while in captivity; and the sound of metal doors banging open or closed. Throughout this section, we will relate the following techniques to Cho’s specific triggers: rice, blossoms, feeling dirty and metal doors.
Three Techniques to Cope with Triggers
♦ Technique #1: Trigger Coping Questionnaire
To help Cho motivate herself to face these triggers, her therapist Marion asked her to answer the following "Trigger Coping Questionnaire" relating to her present coping strategies with the trigger of rice:
- What are your fears about this trigger?
Cho answered, "I have fear that I will embarrass myself and throw up in sight of strangers."
- How have you usually reacted in the past?
Cho wrote, "I run to the bathroom or run away from the smell. I get angry too. In prison, I screamed and cursed the guards. I tried to throw up on them when they beat me. When I smell the rice, I want to tell people around me that I hate them."
- What have been the costs of avoiding this trigger... or of handling the trigger with fear, anger, or other emotions associated with the trauma?
Cho answered, "My favorite foods are Asian foods. I can’t eat at Asian restaurants with friends anymore."
- How would you like to react in the future?
Cho wrote, "I want to be happy with my friends and eat the foods I like and go to restaurants I like."
- What do you stand to gain... if you react in a way you feel would be more beneficial? Cho responded, "I would have more friends. I would be happy and forget the prison."
- How can you break down this trigger... so you can face it more easily?
Because she had trouble with this step, we worked out a system together. Cho decided to stand outside a restaurant that cooked rice for no more than five minutes while practicing the relaxation technique we will discuss later in this section.
Then, when she could cope after five minutes, she increased the time and stood there for ten minutes. Eventually, she entered the restaurant itself where the smell was the strongest. Gradually, Cho reduced her fear of the trigger, but could never fully bring herself to eat it again, understandably. However, the negative effect it had on her social life diminished and she could even sit at the same table while those around her ate rice.
♦ Technique #2: Writing
To help with Cho’s trigger, blossoms, Marion suggested she try writing about what the blossom means to her. Some clients prefer to use positive self-talk in their writing about their triggers, but Cho decided on a different route. In her culture, it was common to write poems about blossoms and the weather associated with it.
First, Cho started out by reading some of her favorite poems to remind her of the calm and sense of beauty that blossoms once inspired. Eventually, she began to write poems of her own about the blossoms and the purity they represented. After a few months of writing, Cho reported that she was growing a small cherry tree in her backyard to symbolize her healthy growth. Her reintroduction to what she had loved about blossoms in the first place helped Cho to overcome her fear of them as her trigger.
♦ Technique #3: Abdominal Breathing Exercise
Because her triggers, feeling dirty, loud metal doors and rice, all caused Cho to feel anxious and on edge, Marion suggested Cho use a relaxation technique. Her choice of relaxation was the "Abdominal Breathing Exercise."
While she stood outside the restaurant, Cho also had extra support from a friend, who held her hand and said soothing things to her. Importantly, this friend was female because Cho associated rice and males with the guards who beat her. Some of your clients might prefer this extra support as well. The "Abdominal Breathing" exercise is designed to decrease body tension by increasing oxygen flow to the brain.
Here are the instructions I gave to Cho:
- Note the level of tension you’re feeling. Then place one hand on your stomach right beneath your ribs.
- Inhale slowly and deeply through your nose into the "bottom" of your lungs—in other words, send the air as low as you can. If you’re breathing from your abdomen, you hand should actually rise. Your chest should move slightly while your abdomen expands.
- When you’ve taken in a full breath, pause for a moment and then exhale slowly through your nose or mouth, depending on your preference. As you exhale, allow your whole body to just let go. You might like to visualize your arms and legs going loose and limp like a rag doll.
- Do ten slow, full abdominal breaths. Try to keep your breathing smooth and regular, without gulping in a big breath or letting your breath out all at once. Remember to pause briefly at the end of each inhalation. Count to ten, progressing with each exhalation.
The process should go like this:
Slow inhale…pause…slow exhale (count one)
Slow inhale…pause…slow exhale (count two)
And so on up to ten. If you start to feel light-headed while practicing abdominal breathing, stop for 30 seconds and then start up again.
- Extend the exercise if you wish by doing two or three sets of abdominal breaths, remembering to count up to ten for each set.
Five full minutes of abdominal breathing will have a pronounced effect in reducing anxiety or early signs of panic. Other breathing exercises include the Calming Breath exercise which we discussed in section 3.
In this section, we presented three techniques to help a PTSD client cope with their triggers: trigger coping questionnaire, writing, and abdominal breathing exercise.
In the next section, we will discuss techniques to help your client recall the trauma safely and accurately: memory prompts, revisiting the scene of the trauma, talking to others, and artistic outlets. Also, we will discuss self-forgiveness and its relation to the recall process.
Peer-Reviewed Journal Article References:
"Advancing complex explanatory conceptualizations of daily negative and positive affect: Trigger and maintenance coping action patterns": Correction to Dunkley et al. (2014) (2014). Journal of Counseling Psychology, 61(2), 263.
Bosmans, M. W. G., van der Knaap, L. M., & van der Velden, P. G. (2016). The predictive value of trauma-related coping self-efficacy for posttraumatic stress symptoms: Differences between treatment-seeking and non–treatment-seeking victims. Psychological Trauma: Theory, Research, Practice, and Policy, 8(2), 241–248.
Lehmann, C., & Steele, E. (2020). Going beyond positive and negative: Clarifying relationships of specific religious coping styles with posttraumatic outcomes. Psychology of Religion and Spirituality, 12(3), 345–355.
Taylor, S., Charura, D., Williams, G., Shaw, M., Allan, J., Cohen, E., Meth, F., & O'Dwyer, L. (2020). Loss, grief, and growth: An interpretative phenomenological analysis of experiences of trauma in asylum seekers and refugees. Traumatology. Advance online publication.
Tsvieli, N., & Diamond, G. M. (2018). Therapist interventions and emotional processing in attachment-based family therapy for unresolved anger. Psychotherapy, 55(3), 289–297.
Online Continuing Education QUESTION
What are three techniques that are useful in helping PTSD clients cope with
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